CQC report explained · a residential care home
What the CQC found at Bishops Way
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors were assured that the home was using protective equipment safely, managing infection risks, supporting testing and keeping its infection control policy up to date.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Requires improvement
- This question was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed in this targeted inspection.
What inspectors found, March 2022
Bishops Way was inspected but not rated; inspectors found strong COVID-19 infection control arrangements.
This was an announced, targeted inspection on 4 February 2022. Inspectors looked at infection prevention and control, visiting arrangements, COVID-19 testing, and whether staff pressures were affecting the service.
Inspectors found that the home had suitable COVID-19 policies and risk assessments. Staff used protective equipment correctly, handwashing points were clean and stocked, and people and staff took part in regular testing.
The home was also meeting the COVID-19 vaccination requirement that applied at the time. The service was inspected but not rated, so this report does not give an overall quality rating or a full assessment of all aspects of care.
COVID-19 planning
The home had policies and risk assessments for managing COVID-19, including for people who declined testing regularly.
“The home had policies and procedures to manage any risks associated with the COVID-19 pandemic.” from the report
Protective equipment
Staff were observed putting on and removing protective equipment correctly. Supplies were available.
“Staff were observed correctly completing donning and doffing PPE.” from the report
Clean and safe environment
Hand hygiene points were accessible, clean and fully stocked. The layout had also been adapted to support safer contact between people and relatives.
“Hand hygiene points in bathrooms and along corridors were clean, accessible and fully stocked.” from the report
Testing and training
People and staff took part in regular testing. Staff had completed infection prevention training and understood their responsibilities.
“Staff had completed training in infection prevention control and had understanding about their roles and responsibilities and the impact of the pandemic on the people.” from the report
Inspectors raised no specific concerns in this report.
- 01What are your current arrangements for visitors entering the home and visiting people safely?
- 02How do you now manage COVID-19 testing for people and staff?
- 03What happens if someone regularly declines testing, and how is their risk assessed?
- 04How would you manage an infection outbreak, and how would relatives be informed?
- 05What are the home's current ratings for Effective, Caring, Responsive and Well-led?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 3 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2020
Bishop's Way was rated Requires Improvement; care was safe and kind, but activities, records and management systems needed improvement.
Inspectors visited without notice on 27 and 28 February 2020. They spoke with people living at the home, relatives and staff. They reviewed care records, medicines records, staff files and management documents.
The home was rated Good for Safe, Effective and Caring. People told inspectors they felt safe. Medicines were managed safely. Staff were described as kind and respectful, and people were supported to make choices and stay independent.
The home was rated Requires Improvement for Responsive and Well-led. Some people did not receive their planned one-to-one hours or meaningful activities. Records were incomplete, and audits did not always identify or fix problems. The overall rating fell from Good at the previous inspection.
People felt safe
People and relatives told inspectors they felt safe. Staff had safeguarding training and knew how to report concerns.
“People were protected from the risks of abuse and harm and people said they trusted staff to keep them safe.” from the report
Medicines were managed safely
Inspectors saw medicines being given in line with care plans. Staff who administered medicines had training and competency checks.
“Medicines were managed safely, people received their medicines in a safe way and systems ensured timely administration of medicines.” from the report
Kind and respectful staff
Staff treated people with kindness and respect. People were supported with privacy, dignity, choice and independence.
“Staff had a caring approach to their work and they demonstrated kindness and respect when supporting and speaking with people.” from the report
Enough staff
Inspectors observed appropriate staffing levels, and relatives and staff said there were enough staff to meet people's needs.
“There were enough staff to support people.” from the report
Planned support was missed
seriousPeople did not regularly receive their daily or weekly one-to-one commissioned support. Meaningful activities were also not always provided or matched to people's interests.
“People did not receive their one to one commissioned hours.” from the report
Activity records had gaps
needs fixingActivity records were poorly maintained, and activities shown on the board were not always offered. This made it harder to check whether people received the support planned for them.
“Activity records were poorly maintained and had gaps in the recording of people's activities.” from the report
Management checks were not strong enough
seriousRecords such as daily notes, handovers and activity logs were incomplete. Audits did not always find problems or lead to enough action to put them right.
“The provider had not operated robust systems and processes to assess, monitor and improve the quality of the service.” from the report
Information was not always accessible
minorEasy-read versions of the complaints and safeguarding policies were not displayed or readily available. Inspectors recommended improving information in line with the Accessible Information Standard.
“there was a lack of accessible information displayed in the service to inform the people who lived there.” from the report
- 01How do you now make sure every person receives all of their planned one-to-one commissioned hours?
- 02How are activities chosen to match each person's interests, and how do you check that advertised activities take place?
- 03What new checks are in place to make sure daily notes, handover notes and activity records are complete?
- 04Has the manager's application to become registered with CQC been completed?
- 05How can residents access easy-read versions of the complaints and safeguarding policies?
This was an unannounced inspection covering all five CQC questions, including the care provided and the premises; Safe, Effective and Caring remained Good while Responsive and Well-led fell to Requires Improvement. This explanation was written from the published report of 22 April 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bishops Way
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2020Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Kirklees
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 86 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Primrose is a very kind and compassionate healthcare professional”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.