Brackley Fields Country House Retirement Home

Updated 17 August 2022

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 completed by one inspector. An Expert by experience made phone calls to people and relatives after the site visit. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Brackley Fields Country House Retirement Home 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. Brackley Fields Country House Retirement Home 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in 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. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service and seven relatives about their experience of the care provided. We spoke with eight members of staff including the nominated individual, registered manager, housekeepers, kitchen staff and care workers.

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.

We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 17 August 2022

About the service

Brackley Fields Country House Retirement Home is a residential care home providing accommodation and personal care for up to 32 people. The service provides support to younger and older people and people with dementia. At the time of our inspection there were 24 people using the service.

People’s experience of using this service and what we found

Records required improvement. We found gaps in the recording of personal care tasks and risk strategies. People’s records did not evidence person centred care was always delivered.

Not all risks were clearly identified and mitigated. Injuries had not always been recorded and follow up information was limited.

Medicine records required improvement. Although people received their medicines, records did not always evidence the reason why an 'as required' medicine had been given and staff did not always have the information required to understand when ‘as required’ medicines should be given.

Not all records were audited to identify when information had not been recorded. Systems and processes to ensure good oversight and improvements were put into place were not always effective.

People, staff and relatives raised some concerns with staffing levels. We were told that due to staffing levels some tasks were not completed, or people had to wait for support to be offered. We made a recommendation regarding reviewing staffing levels.

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; however, the policies and systems in the service did not always support this practice.

The environment was clean, and people had personalised rooms. However, areas of the service required updating.

Staff supported people to have their health needs met. Referrals were made to healthcare professionals as required. Nationally recognised best practice guidance to identify and monitor people who were at risk of developing skin pressure damage or malnutrition was used.

People were supported by kind caring staff who had been safety recruited and received training to understand people’s needs. People and relatives told us staff were kind, caring and compassionate and treated people with dignity and respect.

People, relatives and staff knew how to complain. The registered manager understood their responsibility to open and transparent when things went wrong. Lessons learnt were shared with staff and incidents and accidents were reviewed to identify and trends or patterns to reduce the risk of reoccurrence.

Staff wore appropriate personal protective equipment and the provider followed government guidance on testing for COVID-19.

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 4 September 2019)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines, records and oversight at this inspection.

We have recommended the provider reviews the current staffing levels.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.