Bishops Way

Updated 3 March 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 04 February 2022 and was announced. We gave the service 24 hours notice of the inspection.

Updated 3 March 2022

About the service

Bishop's Way is a care home providing accommodation and personal care to 14 people at the time of the inspection. The service accommodates up to 15 people living with learning disabilities or mental health related needs in one building.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 15 people. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were discouraged from wearing anything that suggested they were care staff when coming and going with people.

People’s experience of using this service

The outcomes for people did not fully reflect the principles and values of Registering the Right Support as people had limited inclusion. People using the service did not always receive planned and co-ordinated person-centred support that was appropriate and inclusive for them. For example, people did not always receive person-centred support with their activities. We received mixed feedback about activities within the home; some people felt there were activities to engage with, whilst other people told us activities displayed on the activity board were not always offered. Activities displayed on an activity board does not support the principle of meaningful lives that include control, choice and independence. Meaningful activity was not always provided and people did not receive their one to one commissioned hour’s.

There was a lack of accessible information displayed in the service to inform the people who lived there. For example, easy read versions of the provider’s complaints policy or safeguarding policy was not on display or readily available. We have made a recommendation about the provider considering best practice in relation to the Accessible Information Standard (AIS).

Governance systems required improvement and records were poorly maintained. Audit systems were not robust, they did not always identify the issues we found during the inspection, and where they did, enough action was not taken to resolve the issue.

The service lacked personalisation in particular to people’s bedrooms. The manager told us they were in the process of asking people how they would like their rooms decorated. We also found there was a lack of signs to identify communal areas and doors. We have made a recommendation about the provider considering signage for communal areas to ensure the premises meets the needs of people who lived there.

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

People told us they felt safe. Staff had a good understanding of how to safeguard people from abuse. Medicines were managed safely.

People were supported to express their views about their care. People’s independence was promoted. Staff gave us examples about how they involved people doing certain aspects of their day to day activities which supported them to maintain their independence. Staff had a caring approach to their work and they demonstrated kindness and respect when supporting and speaking with people.

Staff felt valued and supported by the management team. The service worked in partnership with other to meet the needs of people. The manager demonstrated how they worked in partnership with local hospitals, the local authority, safeguarding teams and other healthcare professionals.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was good (published 04 September 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to good governance and person-centred care at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.