The Care Quality Commission
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  • Care home

Archived: Saint John of God Hospitaller Services - Bedes Close

Overall: Good read more about inspection ratings

8, 10, 11 Bede's Close, Thornton, Bradford, West Yorkshire, BD13 3NQ (01422) 438540

Provided and run by:
Saint John of God Hospitaller Services

All Inspections

23 June 2015 & 12 August 2015

During a routine inspection

On the 23 June 2015 and 12 August 2015 we inspected 8, 10 and 11 Bedes Close. Both days of inspection were unannounced. The pharmacist attended the inspection in 23 June 2015, and due to high risk work being undertaken at the time, the lead inspector was unable to attend the remainder of the inspection until 12 August 2015.

8, 10 and 11 Bedes Close provides accommodation for persons requiring nursing and personal care to a maximum of 18 people who are living with learning disabilities. All the accommodation is in single rooms and the service is located in the residential area of Thornton, close to Bradford city centre. The Service is split between three, six bedroom bungalows.

There was not a registered manager in place. The last registered manager deregistered with the Care Quality Commission (CQC) in 2013. The service had an acting manager who was in the process of registering with the CQC. A registered manager is a person who has registered with the 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.

Staff were recruited in line with the provider’s policy. Relevant background checks had been completed and were monitored.

People were protected from the risk of abuse as staff had received training in safeguarding people and had good understanding of their roles and responsibilities if they suspected abuse was happening. The manager also shared information with the local authority and the Care Quality Commission when required.

People received their medicines as prescribed and the management of medicines promoted people’s safety. Medicines were audited regularly to maintain a high standard.

Staffing was maintained at appropriate levels to provide people with effective support. Staff had received appropriate training to maintain their competency. Staff felt supported however there were gaps in supervisions and appraisal meetings.

People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We saw best interest meetings had been held when required.

Staff encouraged people to be as independent as possible. Staff spent time getting to know people to provide a more person centred service.

Staff were aware of the basic principles of the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were protected from the risks of inadequate nutrition. Specialist diets were provided if needed. Referrals were made to health care professionals when required.

People’s care records were person-centred to ensure people received support in a planned and responsive way. People that used the service, or their representatives, were encouraged to contribute to the planning of care records.

People had unrestricted access to their families and their friends. They also had opportunities to participate in a variety of social and leisure activities to help them lead a fulfilling life.

Systems were in place to monitor the quality of service provision. We saw regular audits had identified shortfalls which had been remedied.

People that used the service or those acting on their behalf felt they could report any concerns to the management team and they would be taken seriously.

27 June 2014

During a routine inspection

During our inspection we looked for the answers to five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, staff supporting them and from looking at records.

Is the service caring?

We observed staff treating people with respect and dignity. Sufficient time was offered to all people to respond to any. People appeared clean and tidy and staff acted in line with peoples care plans.

Is the service responsive?

We found there were systems in place to make sure the service was being run properly. We saw when issues had arisen actions plans had been put in place to show who was going to tack action to make sure the issue was resolved. We looked at previous audits and found all actions completed. Any concerns relatives had raised were acknowledged and responded to in a timely fashion. Staff told us they were confident any concerning information would be investigated and acted on.

Is the service safe?

Care plans were linked with risk assessments to identify, reduce and remove risk where possible. We saw staff acted in line with risk assessment guidance. Staffing levels were sufficient to support people when help was needed. Assistive technology was in place to monitor people leaving their beds in the night.

Is the service effective?

We found staff acted in line with care plans which were reviewed on a regular basis. Before people came to live at the service they had an assessment of their needs to see if the service could support them fully. We saw in surveys relative's had completed they felt people's needs were being met. Staff told us that people were not left wanting something for long periods of time.

Is the service well led?

We found an effective quality assurance system was in place to constantly improve quality within the service. Staff felt well supported and told us they were clear on their roles and responsibilities. We saw evidence of concerns being brought to the managers' attention and these being investigated.

5 March 2014

During an inspection looking at part of the service

Our inspection on the 17 September 2013 found concerns about how people were protected against the possibility of financial abuse. Following the inspection the provider wrote to us and told us they would take action to ensure they were compliant with these essential standards.

At this inspection we found improvements had been made to ensure that people when people went on holiday the financial records protected them against the possiblity of financial abuse.

28 January 2014

During a routine inspection

We carried out this visit to look at the arrangements for handling medicines. We checked the records and a sample of medicines for eight people who lived in Bedes Close. We spoke with the manager, a care worker and a nurse. Due to people having communication difficulties we found it difficult to obtain the direct views of people who lived in the home about how their medicines were handled.

Overall we found some improvements were required to help make sure medicines are handled safely.

17 September 2013

During an inspection looking at part of the service

Our inspection on the 25 February 2013 found we had concerns the provider did not have sufficient qualified and skilled staff to meet people's needs. Also risk assessments and care plans did not always contain appropriate information to prompt staff on how best to support people and this could have put people at risk. The provider wrote to us in April and July 2013 and told us they would take action to ensure they were compliant.

At this inspection we looked at what improvements had been made and found the provider had taken action to ensure there were sufficient qualified and skilled staff to meet people's needs. Also people were now protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

We were unable to speak to people using the service during this inspection because they had complex needs, so we observed the care, staff provided, to people for over three hours in bungalows 10 and 11. We saw peoples care was mostly delivered in line with their individual care plans. We talked to three peoples relatives who told us peoples care needs were met and described the staff as helpful and caring.

However we found the systems in place to protect people from financial abuse were not always followed by staff and this could have put people at risk.

25 February 2013

During an inspection looking at part of the service

We were not able to speak with people who used the service because most had complex needs which meant they were not able to tell us about their experiences. We used a number of different methods to help us understand people's experiences, such as reviewing care records, observing care and speaking with relatives.

We spoke with three people's relatives. They told us they were happy with the care and support their relative received. They all said they felt involved in their relative's care and that staff kept them informed if there were any changes to their relatives care needs.

We saw the provider had made improvements which ensured people were safeguarded against the risk of abuse. We also saw the provider had assessed and monitored the quality of service people received. There was also a plan in place to ensure staff were supported to deliver care and treatment to people safely and to an appropriate standard.

We found evidence there were not enough qualified, skilled and experienced staff to meet people's needs. We also found evidence people were not always protected from the risks of unsafe or inappropriate care and treatment as the care records we saw were not fit for purpose.

25 September 2012

During a routine inspection

We were unable to speak with all of the people who used the service because they had complex needs which meant they were not able to tell us their experiences. We used a number of different methods to help us understand the experiences of people using the service, such as reviewing care records and speaking to the relatives/representatives of four of the people who lived at the home and observing staff engaging with people living in the bungalows.

Four relatives described it as 'fantastic' and one told us 'it has just got better in terms of the care they take and the interest they take in the individual.' Two provided us with specific information about how the staff had arranged for new equipment to suit their relative's needs'. Three relatives confirmed that the staff were proactive in accessing appropriate health professionals when needed and all explained they were fully informed about their relatives care.

However, despite the positive comments people made, we found evidence that people were not always receiving the specific care they needed and the provider did not have an effective system to regularly assess and monitor the quality of service that people received. Some staff had not received appropriate training. Also people who used the service were not protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.