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Inspection Summary


Overall summary & rating

Good

Updated 15 February 2019

The inspection took place on 22 and 28 January 2019. The first day of the inspection was unannounced.

We last inspected the service in February 2018 and found the provider had breached two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. These related to the systems and processes used to manage medicines safely and record keeping. We asked the provider to complete an action plan to show what they would do to improve the service.

Bishopsgate Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates 47 people across three floors. At the time of the inspection 42 people were being supported in the home, 15 requiring nursing care and some were living with dementia.

The service had a registered manager in post. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

At this inspection we found the provider had taken action to improve.

The provider had introduced additional documentation to support the administration of medicines. Medicines were managed by staff trained in the administration of medicines. Observations demonstrated people received their medicines safely. The provider had employed a clinical lead to provide additional support to nursing staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Risks to people were assessed and plans put in place to mitigate against them. Risk assessments were reviewed regularly or when there was any change in the person’s needs. Risk assessments for the environment such as slips, trips and falls were in place and reviewed regularly.

Recruitment processes were in place with all necessary checks completed before staff commenced employment. Nurses had their professional identification numbers (PIN) checked on a regular basis.

The provider used a dependency tool to ensure staffing levels met the needs of the people living in Bishopsgate Lodge. Staffing rotas were completed in line with the dependency tool.

The provider had a business continuity plan in place for staff guidance in case of an emergency. People had Personal Emergency Evacuation Plans (PEEPS) in place which were updated regularly.

Staff were aware of safeguarding processes and knew how to raise concerns. Where lessons could be learnt from safeguarding concerns, these were used to improve the service. Accidents and incidents were recorded and monitored as part of the provider’s quality assurance system.

The provider ensured appropriate health and safety checks were completed. We found up to date certificates were in place which reflected gas safety checks and mobility equipment checks.

We found staff received regular supervision and an annual appraisal. Opportunities were available for staff to discuss performance and development. Staff training which the provider had deemed mandatory was up to date.

People’s nutritional needs were assessed and we saw people enjoying a varied diet, with choices offered and alternatives available. People were supported with eating and drinking in a safe, dignified and respectful manner. People had access to healthcare professionals when necessary and were supported with health and well-being appointments.

The provider had systems and processes in place to ensure the principles of the Mental Capacity Act 2005 (MCA) were being met.

People and relatives

Inspection areas

Safe

Good

Updated 15 February 2019

The service was safe.

The provider had introduced systems in place to manage more medicines safely.

Risks to people were assessed and control measures were recorded for staff support and guidance.

Staffing levels were appropriately to the needs of the people using the service.

Effective

Good

Updated 15 February 2019

The service was effective.

Staff received regular supervision and an annual appraisal. Training needs were monitored, with courses arranged when necessary to keep staff up to date.

People received a varied healthy diet. Staff monitored people’s nutritional needs on a regular basis.

Staff understood the principles of the Mental Capacity Act 2005. People were supported in the least restrictive way possible.

Caring

Good

Updated 15 February 2019

The service was caring.

Staff demonstrated positive relationships with the people they supported.

People felt the staff supported them with dignity and respect.

The provider had information regarding advocacy which was available to people and their relatives.

Responsive

Good

Updated 15 February 2019

The service was responsive.

Care plans were personalised and reviewed regularly. Any changes to need were reflected in the care plans.

People had access to a broad range of activities in the home and out in the community.

The provider had a complaints policy and procedure in place. People and relatives knew how to complain.

Well-led

Good

Updated 15 February 2019

The service was well led.

People and relatives felt the service was well managed.

The provider had a comprehensive quality assurance system to monitor the quality and safety of the service.

The registered manager ensured the service had links with stakeholders and the local community.