Background to this inspection
Updated
11 August 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by 2 inspectors.
Service and service type
Breach House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Breach House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was no registered manager in post. The manager in post had submitted their application to register with CQC. Following our inspection the manager left their post.
Notice of inspection
This inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with 3 people who lived at the home and 4 people’s relatives. We also spoke with the manager, deputy manager, 2 senior carers and the chef. We looked at the care records and medicines records for the 5 people living in the home. We checked the care people received matched the information in their records. We looked at records relating to the management of the service, including audits, and recruitment checks carried out within service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
Updated
11 August 2023
About the service
Breach House is a residential care home providing regulated activity of accommodation and personal care to up to 34 people. The service provides support to older people some of which have dementia. At the time of our inspection there were 5 people using the service.
People’s experience of using this service and what we found
Improvements had been made to the assessment and management of risks however further improvements were needed. Improvements had been made to the administration of medicine though further improvements were required to ensure the safe storage of medicines. Staff were recruited safely, and a sufficient number of staff were employed to meet people’s needs. Staff understood and followed infection control measures, and when things went wrong, the provider had learned lessons and developed improved systems.
The provider had introduced audit systems to monitor the safety and quality of the service, but these required further development and time to embed. A positive person-centred culture was promoted, and the manager promoted learning and development.
Staff gained the skills and knowledge necessary to meet people’s care and nutritional needs through regular training. People were supported to access healthcare as needed; through positive links the manager had established with external professionals.
We found an improved culture in the home. The manager and staff were caring and respectful of people which ensured a person-centred approach to the people living in the home. People’s views were sought with equality, privacy and dignity promoted.
Staff were responsive to the needs of each individual. The provider had introduced a new complaints procedure to manage and respond to any complaints they received.
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 21 July 2022). At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
This service has been in Special Measures since 21 July 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.