Broome End

Broome End is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates 37 people, some of whom are living with dementia, in one adapted building. At the time of our inspection there were 27 people using the service.

Following our last inspection on 12 July 2017 the service was given a final rating of 'Requires Improvement'. A breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified because the provider failed to have effective systems in place to ensure people’s medicines were stored and managed safely. Improvements were also needed in relation staffing levels, due to high reliance on agency resulting in people not being supported by staff that understood their needs and a lack of cohesion amongst staff. Limitations on staff time had meant that the care provided was largely task focussed, with little meaningful stimulation or interaction. We also identified that the governance and quality assurance systems were not effective and had not identified failings in the service, found at the inspection.

At this inspection we found significant improvements had been made. A new manager was in post and had registered with the Care Quality Commission (CQC) to manage the service. A registered manager like registered providers, 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.

Systems had been implemented which were used to continuously assess and monitor the quality of the service. The registered manager and staff had a clear understanding of what was needed to ensure the service continued to develop, and ensure people received high-quality care.

There were sufficient numbers of staff available to meet people’s needs. Recruitment remained an issue for the service largely due to the rural location. However, three new care staff had been recruited, and a small pool of bank and regular agency staff were being used, to provide continuity. Since our last inspection a deputy manager had been recruited. Where previously the registered manager had been overseeing all aspects of the service, the additional resources had freed up their time to focus more on their managerial duties.

This service was selected to be part of our national review, looking at the quality of oral health care support for people living in care homes. The inspection team included a dental inspector who looked in detail at how well the service supported people with their oral health. This includes support with oral hygiene and access to dentists. We will publish our national report of our findings and recommendations in 2019. However, for this inspection we found oral health training for staff was basic. The deputy manager had taken on the role of oral health champion and outlined plans to improve oral health care, including training. Champions are staff that have shown a specific interest in specific areas. They are essential in developing best practice, by sharing their leaning and acting as role models for other staff.

Staff felt supported by the management team, in particular the registered manager. Staff were encouraged to further their knowledge and skills through a combination of training methods, including eLearning as well as external trainers coming to the service. Staff’s competencies had been assessed to ensure they had understood what they had learnt and were able to effectively apply it to their daily practice.

People were protected from risk of harm and staff had a good understanding of processes to keep people safe and how to report concerns. Safeguarding incidents were managed well. Peoples’ medicines were being managed safely. A thorough recruitment and selection process was in place, which ensured staff recruited had the right skills and experience, and were suitable to work with people who used the service. The deputy manager had engaged with the local authority Prosper scheme. This scheme is aimed at promoting new ways of reducing preventable harm from falls, urinary tract infections and pressure ulcers. The implementation of the Prosper programme, combined with the use of assisted technology, such as sensor matts, had clearly had an impact on reducing the number of falls, in the service.

Our previous inspection found, people’s meal time experience varied according to which staff member was assisting them. At this inspection, whilst we found improvements had been made, there were isolated incidents where staff interaction was lacking, but the remainder of the meal time was seen to be a positive, and sociable experience. People were supported to eat and drink enough to maintain a balanced diet. People were supported to live healthier lives and had good access to healthcare services, where required.

Although, improvements to the premises had been made, through a programme of redecoration, further consideration in conjunction with good practice guidance was needed in relation to the suitability of the layout and living space in the dementia unit.

People, their relatives, friends and health professionals were complimentary about the attitude and capability of the staff, the registered manager and the care provided. The community matron, district nurse and a student nurse visiting the service during our inspection all commented that they had seen a great improvement in the service since the new manager came on board. Staff had developed good relationships with people using the service. Staff treated people with kindness, promoted their independence and respected their privacy and dignity.

People were supported to express their views and be actively involved in making decisions about their care. Consent to care and treatment was being managed and sought in line with legislation and guidance.

The provider was meeting the requirements of the Accessible Information Standards. This set of standards sets out the specific, approach for providers of health and social care to identify, record, share and meet the communication needs of people with a disability, impairment or sensory loss. People had access to a range of activities, depending on their interests, within the home and via external sources, and chose if they wanted to take part. Posters were displayed around the service advertising events and asking people for their suggestions and ideas. People were supported to follow their chosen faith and religious practices.

Systems were in place to ensure people’s concerns and complaints were listened and responded to. Records showed complaints had been investigated in full and an apology provided to the complainant. Complaints had been used to improve the quality of the service. No one currently using the service was receiving end of their life care, however feedback from people’s relatives in thank you cards and discussions with staff confirmed people were supported to have a comfortable, dignified and pain-free death.

We last inspected the service on 26 April 2016 and rated the service as requires improvement. This was because we had some concerns around low staffing levels, especially at night, and the lack of support given to the registered manager. During this inspection we found that although some improvements had been made to the management structure of the service we continued to have concerns about low staffing levels at night and a high reliance upon agency staff resulting in a lack of cohesion amongst staff.

At the time of the inspection there was not a registered manager in post. Since the previous inspection a new home manager and deputy manager had been appointed. The new manager was in the process of registering with the commission. A registered manager is a person who has registered with the Care Quality Commission 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.

Whilst care plans were person centred and detailed in places some lacked specific information about people’s care. This meant that they did not consistently reflect the needs of people and at times staff lacked guidance on how to minimise potential risks.

A high reliance upon agency staff meant that people could not be assured that they were being supported by staff who knew them well. Consequently, people did not always receive care and support that was suited to their individual needs and preferences. Staff were not always deployed effectively to meet people's needs and at meal times there were not enough staff available to support people to eat and drink in a dignified manner.

Effective systems were not in place to ensure that medicines were consistently stored and managed safely.

Staff had completed a variety of training modules. However, they were largely provided through on line sessions and there was no evidence to show that following the training staff had their competencies assessed to ensure that they had understood what they had learnt and were able to effectively apply it to their daily practice.

Whilst staff were caring in their approach limitations on their time meant that the care provided was largely task focussed. Some people participated in a variety of activities however, people with a greater need were left for periods of time with little meaningful stimulation or interaction.

Whilst systems were in place to monitor the quality and safety of the service records showed that they had not always been used effectively. This meant that the management team did not have a clear oversight of the service.

Staff understood how to recognise signs of abuse and were confident in the action that they would take to raise any concerns.

The service had a recruitment process in place to ensure that staff were safe to work with people living at the service.

Staff worked in line with the principles of the mental capacity act and understood their responsibilities to ensure people were given choices about how they wished to live their lives.

The manager and deputy manager were a visible presence around the service and supportive and accessible to staff. Together they had worked hard to develop effective working relationships with local healthcare professionals.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 28 April 2016 and was unannounced.

The service provides accommodation for up to 37 older people some of whom may be living with dementia. At the time of our inspection 26 people were living at the service. We last inspected the service on 16 July 2015 in response to concerns that had been raised with us. At that inspection we rated the service Requires Improvement but did not carry out a fully comprehensive inspection. This inspection was carried out to check on the improvements we required and look at areas of the service not previously checked.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission 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 trained in keeping people safe from abuse and understood their responsibilities should they suspect abuse had occurred. Staff were able to outline how they would report any concerns they had.

Risks to people’s health and wellbeing were assessed and reduced as much as possible.

Staffing levels were sometimes low, especially at night, and did not always reach the level the service had assessed as safe.

Medicines were well managed and regularly audited.

Staff received a structured induction and training was provided to equip them to carry out their roles. Experienced staff demonstrated a good knowledge of the people they were supporting and caring for and knew people’s particular preferences and wishes with regard to their care.

We saw that staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Staff demonstrated a basic understanding of the principles of the MCA and DoLS.

People who used the service were very positive about the food and were able to exercise choice about their meals. Mealtimes were sociable occasions which people greatly enjoyed. People identified as being at risk of not eating enough were referred to appropriate healthcare professionals and monitored.

People were supported to access healthcare professionals when they needed them and the staff involved relevant professionals when a person’s health declined. The GP expressed concerns that sometimes the service did not alert them promptly enough when someone became unwell and sometimes information about people’s health was not accurate. The district nursing team also had concerns and there was a poor relationship between them and the manager of the service which had the potential to place people at risk.

Staff were caring and committed and we saw that people were treated respectfully and their dignity was maintained. The atmosphere was of a friendly place and the good relationships between staff, the people they were supporting and visiting relatives were observed throughout the service. Relatives were very positive about the caring nature of the staff.

People, or their relatives, were involved in assessing and planning their care and plans were regularly reviewed.

People were supported to follow different interests and hobbies and to go out on trips. People living with dementia and those who did not wish to take part in structured activities were provided with one to one sessions.

There had been no formal complaints but informal complaints were logged and investigated in line with the provider’s complaints procedure, and to people’s satisfaction.

The service had an open culture and the manager was approachable. The manager was not supported by a deputy, and had not had consistent support for over a year. The provider had not taken steps to successfully address this which was a concern as the issue of the breakdown in the relationship with the district nursing team had the potential to place people at risk and the manager was dealing with this on their own.

An effective and wide ranging audit system was in place and records were well organised and easily located.

If you want to see the evidence supporting our summary, please read the full report.

Is the service caring?

We spoke with three people who used the service. We were not able to speak with some of the other people due to their communication needs. One person said to us, "The staff are lovely here; they look after me well." Another person said, "I feel safe here." We observed the care and attention people received from staff. All interactions we saw were appropriate, respectful and friendly.

Is the service responsive?

We saw that care plans and risk assessments were informative, up to date and regularly reviewed. The provider used an outside company to assist them with monthly monitoring visits and responded appropriately to action plans set and suggestions made. The manager responded in an open, thorough and timely manner to complaints. Therefore people could be assured that complaints were investigated and action was taken as necessary.

Is the service safe?

The accommodation was adapted to meet the needs of the people living there, was suited to caring for people with limited mobility and was properly maintained. The home was warm and clean and was personalised to the people who lived there. People were protected by robust staff recruitment systems. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines.

Is the service effective?

People we spoke with were satisfied with the care and support they received. No one raised any concerns with us. This was consistent with generally positive feedback from people reported in the provider's own annual quality assurance survey.

Is the service well led?

Staff said that they felt well supported and were able do their jobs safely. The provider had a range of quality monitoring systems in place to ensure that care was being delivered appropriately by staff, that the service was continuously improving and that people were satisfied with the service they were receiving.

Some people who used the service at Broome End were not able to tell us about their experiences so we used a number of different methods to help us understand. We observed the interactions between people who used the service and the staff working at the home and we listened to everyday events and activities during the course of the day. We saw that people who used the service initiated interactions, approached staff with confidence and were responded to in a warm and respectful way.

We spoke with four relatives during our visit to the service on 19 August 2013 and after that visit, we spoke on the telephone with two other relatives who frequently visited the service. They all told us that they felt that people were provided with good care and had support for social and leisure activities.

Broome End had undergone considerable refurbishment over the past six months since the home had changed ownership. The first and second floor programme had been completed. The provider told us that the entire refurbishment programme was planned to be finished, including a ground floor lounge extension, by March 2014.