The Care Quality Commission
  • Care Home
  • Care home

Archived: Bywater Lodge

Overall: Good read more about inspection ratings

1 Leeds Road, Allerton Bywater, Castleford, West Yorkshire, WF10 2DY (01977) 551612

Provided and run by:
Tri-Care Limited

All Inspections

14 December 2015

During a routine inspection

We inspected the service on 14 December 2015. The visit was unannounced. Our last inspection took place in October 2014 and at that time; we found the provider was in breach of four regulations and asked them to take action to rectify this. The provider sent us an action plan telling us what they were going to do to ensure they were meeting the regulations. On this visit we checked and found sufficient improvements had been made in these areas.

Bywater Lodge provides accommodation and care for up to 44 older people who may be living with dementia or other mental health conditions. The home is purpose built, set in its own gardens and there is parking available. The home is divided over two floors. There is a large lounge and dining room on both floors for people to use with lift access. There is also a café area. People living in the home have single en-suite rooms.

At the time of this inspection the home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The person managing the service had submitted an application to register with the CQC.

At our previous inspection we found the provider was in breach of Regulation 14 Health and Social Care Act 2008 (Regulated Activities) Regulation 2010, Meeting nutritional needs. Under the new regulations this equates to Regulation 14 Meeting nutritional and hydration needs of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence the provider had taken action and was meeting the requirements of the regulation. The lunch time meal experience was pleasant for people living in the home and choice and support was offered. This meant people received a suitable diet and had sufficient to eat and drink.

At our previous inspection we found the provider was in breach of Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulation 2010, Consent to care and treatment. Under the new regulations this equates to Regulation 11 Need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence the provider had taken action and was meeting the requirements of the regulation. The care plans we looked at showed the provider had assessed people in relation to their mental capacity. There had been Deprivation of Liberty Safeguards applications completed.

We also found the provider in breach of Regulation 22 and 23 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Staffing. This equates to Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence to demonstrate the provider had taken action and was meeting the requirements of this regulation. Staffing levels were appropriate to people’s care and support needs safely, and people told us there were enough staff. We saw evidence of use of bank staff to ensure gaps on the rota were covered and saw the provider was in the process of recruiting new staff. Staff told us they felt well supported, although we found that supervisions and appraisals had not been kept up to date. The manager was aware of this and had already taken steps to improve this. A programme for staff supervision and appraisal had started.

Staff training was comprehensive and kept up to date, meaning they had the necessary skills to provide care and support to people.

People’s care needs were assessed and care plans identified how care should be delivered. People and relatives we spoke with told us they were very happy with the service they received and staff were kind and caring, treated them with dignity and respected their choices.

People had regular contact with healthcare professionals; this helped ensure their needs were met.

We saw evidence of a programme of activities in the home and were told by the manager this was developing with input from people who used the service and staff.

Policies and procedures were in place to ensure people who used the service were protected from abuse. Staff received training in the safeguarding of vulnerable adults and knew how and when to report any concerns. In addition we found the provider managed accidents and incidents well, making appropriate healthcare referrals where needed. Systems for reporting incidents to the local safeguarding authority and the CQC were robust and well managed.

Staff and people who used the service were very positive in their feedback about the new management and leadership of the home. People had opportunity to comment on the quality of service and influence service delivery. Complaints were investigated and responded to appropriately.

3 October 2014

During a routine inspection

This was an unannounced inspection carried out on the 3 October 2014. At the last inspection in August 2013 we found the provider met the regulations we looked at.

Bywater Lodge provides accommodation and care for up to 44 older people who may be living with dementia or other mental health conditions. The home is purpose built, set in its own gardens and there is parking available. The home is divided over two floors. There is a large lounge and dining room on both floors for people to use with lift access. There is also a café area. People living in the home have single en-suite rooms.

At the time of this inspection the home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found people were cared for, or supported by, skilled and experienced staff. However, appropriate staffing levels were not always maintained on both floors of the home. This is a breach of Regulation 22, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

Staff had only completed mandatory training at induction and there was no programme of condition related training or staff supervision and appraisal. This is a breach of Regulation 23 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Staff told us they had received Mental Capacity Act 2005 training. However, not all staff had a good understanding of how to ensure the rights of people as the training was not embedded. The care plans we looked at showed the provider had not assessed people in relation to their mental capacity. There had been no Deprivation of Liberty Safeguards applications completed and the manager was not aware that they needed to be. This is a breach of Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

People’s nutritional needs were not always being met. People were not supported to eat or drink enough to maintain their health. This is a breach of Regulation 14 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

People told us they felt safe in the home and we saw there were systems and processes in place to protect people from the risk of harm.

People received their prescribed medication when they needed it and appropriate arrangements were in place for the storage and disposal of medicines.

People’s physical health was monitored as required. This included the monitoring of people’s health conditions and symptoms so appropriate referrals to health professionals could be made.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. Care plans contained a good level of information setting out exactly how each person should be supported to ensure their needs were met. Care and support was tailored to meet people’s individual needs and staff knew people well. The care plans included risk assessments. Staff had good relationships with the people living at the home and the atmosphere was happy and relaxed.

We observed interactions between staff and people living in the home and staff were respectful to people when they were supporting them. People were not always supported to complete questionnaires enabling them to express their views about the home.

A range of activities were provided both in the home and in the community. However, these were not always meaningful and simulating. Staff told us people were encouraged to maintain contact with friends and family.

The manager investigated and responded to people’s complaints, according to the provider’s complaints procedure. There were not always effective systems in place to monitor and improve the quality of the service provided. Staff were supported to raise concerns and make suggestions when they felt there could be improvements and there was an open and honest culture in the home.

15, 16, 19 August 2013

During a routine inspection

At the time of our inspection Bywater Lodge were in the process of recruiting a new Registered Manager and a new unit manager. During our visit we spoke with the area operations manager, the provider's compliance and quality inspector, the personal assistant responsible for administration, and four members of the care staff. We also spoke in detail with one person who lived in the home and three visiting relatives.

We found the home had processes in place to assess, support and monitor people's capacity to make decisions. We saw appropriate action had been taken where people were not always able to make their own decisions and choices.

We saw people who lived there had easy access to their bedrooms and to communal lounge, dining and garden areas. We saw communal areas were welcoming, clean and tidy. People's rooms were decorated according to their personal taste and their individual needs.

Relatives and people living in the home spoke positively about the care home staff. One person who lived in the home commented: 'The staff are all good. They are very patient and supportive.' One person who lived in the home described how staff discussed her care plan with her. 'They discuss everything and check I agree with what they've put.'

At the time of our visit, the home was in the process of introducing a new filing and archiving system. The new system looked well organised and easy to follow making the process easier for staff to manage efficiently.

25 April 2012

During a routine inspection

The majority of people living at Bywater Lodge suffer from some form of memory loss and have difficulty expressing themselves, because of this only a small proportion of the people we met during our visit were able to tell us what they thought about the service.

Two people said they were 'very happy' at Bywater Lodge. One person said, "Staff have been very kind to me during my recent illness and nothing has been too much trouble." One of the five people, who were able to speak to us, said they were involved in their care, with their preferences being sought and taken into consideration. This included being enabled and supported to live their lives as independently as they wished. The person also said they were able to express their views freely and explained how staff were 'sensitive' when she was being helped to dress and undress and that staff 'never made her feel embarrassed.'

People told us that they were happy with the care and treatment they were receiving. One person said, "I am a fussy eater and the staff try hard to find things I like.' Another person said, 'It can't be like your own home but it is quite good."

We spoke with the relative of one person. They told us; "The care is very good here."

29 November 2011

During an inspection looking at part of the service

People who use the service were not able to tell us about their views of the service they receive. However, through our observations, we saw that people seemed confident in their surroundings and in their interactions with staff.

1 September 2011

During an inspection looking at part of the service

We carried out a review of compliance at the above location on 8 and 9 August 2011 to check whether the regulated activity being carried on there complies with the requirements of the Health and Social Care Act 2008 and the Health & Social Care Act 2008 (Regulated Activities) Regulations. During the review, we identified failure to comply with a number of regulations.

We issued urgent compliance actions on 11 August 2011 in four outcome areas because the failures to protect people were too serious to wait for the publication of the full report about our review of compliance. We requested a report form Bywater Lodge, by 19 August 2011, to tell us how they would make these areas safe.

As a result of this inspection, we found the service did not fully protect people against the risks associated with the unsafe use and management of medication by means of the making of the appropriate arrangements for the recording, handling, administration and use of medicines. Due to the high risk associated with this area, we have taken enforcement action against Tri-Care Limited and issued a warning notice to be complied with by 7 November 2011.

This report focuses on the four areas we had immediate concerns about.

Overall people who use the service did not make any specific comments relating to the outcomes due to the nature of their condition.

8 August 2011

During an inspection in response to concerns

We felt the above failures were too serious to wait for the publication of this report.

We requested a report showing how the provider is achieving compliance in regulation 9 (Outcome 4 - Care and welfare of people who use services), regulation 14 (Outcome 5 - Meeting nutritional needs), regulation 13 (Outcome 9 - Management of medicines) and regulation 10 (Outcome 16 - Assessing and monitoring the quality of service provision).

Where they were not, we requested they let us know the action they will take in order achieve compliance with the relevant regulations.

This report was requested to be sent to us by 19 August 2011. We made this request under regulation 10(3) of the Regulated Activities Regulations 2010.

Overall people who use the service did not make any specific comments relating to the outcomes due to the nature of their condition.