Archived: Brundall Care Home

At the last inspection on 5 July 2016 the service was rated ‘Good’ overall. At this inspection we found that the service had been unable to sustain the improvements we observed at our last inspection. We identified widespread failings in the service which put people at risk of harm. The service is now rated ‘Inadequate’ overall.

The service did not have a registered manager. However, the person managing the home at the time of inspection was in the process of registering with us. 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.

At the 5 July 2016 inspection the service achieved a rating of ‘Good’. This was following two previous inspections where the service had been rated ‘Inadequate’ overall and where the Commission took enforcement action against the service. The provider had ineffective systems in place to oversee the service and ensure its compliance. This meant that we found at this visit the improvements that had been made previously had not been sustained.

Risks to people were not always identified and clear plans to mitigate risks were not in place for all the people whose records we reviewed. The manager and care staff did not always recognise risks in the environment, such as items which could cause potential harm. Care planning did not always make it clear how care should be delivered to ensure people’s safety.

Care planning around nutrition and hydration was not consistently clear about the support people required. The service did not follow National Institute for Health and Care Excellence (NICE) guidance around the assessment of nutrition and the actions required when people were assessed as at risk of malnutrition. NICE guidance is publically available and provides the reader with up to date information about best practice in providing care to people.

There were shortfalls in the way people’s pressure care needs were assessed and care planned. This put people at risk of a deterioration in their skin integrity.

People and/or their representatives were not consistently involved in the planning of care. Care plans and the records we reviewed did not reflect people’s views and preferences.

People’s records were not consistently personalised to include information about their likes, dislikes, hobbies and interests. Where people were living with dementia, there were not sufficient life histories in place. Care plans did not set out people’s preferences around how they would like their care delivered. This meant that staff did not have the information needed to deliver personalised care.

Sufficient end of life care plans were not in place. The service had not referred to NICE guidance and the Gold Standards Framework to create care plans that set out people’s wishes and needs in sufficient detail.

The environment was not safe. There were hazards which could compromise staff’s ability to evacuate the building quickly in the event of a fire and some fire exit and evacuation signs were confusing. There were exposed hot water pipes throughout the service which posed a risk of burns if people were to touch or fall against them. We tested a sample of hot water taps and found two did not have valves to stop them reaching scalding temperatures. There were substances and items in some people’s bedrooms that could be harmful to people if ingested in error. These included prescription creams.

The audit and management systems in place at the service were ineffective. The manager had not independently identified the serious safety concerns we identified and taken action to protect people. Whilst audits carried out on behalf of the provider had identified some of the shortfalls, prompt action had not been taken to ensure people were protected from harm.

Some parts of the service were cold and this had not been identified by staff or the manager. Staff opened windows around the service and did not have an awareness of how to support people to maintain a comfortable temperature.

Some interactions we observed were not kind and caring. We observed that staff became frustrated with some people using the service and did not demonstrate a knowledge and understanding of people living with dementia. There were no plans in place to guide staff on supporting some people who had behaviours that they found challenging.

People’s capacity to make decisions was assessed and Deprivation of Liberty Safeguards (DoLS) applications had been made where appropriate. However, we observed that staff did not always provide people with opportunities to make independent decisions or request their consent.

There were not enough staff to provide people with care and support at the time they needed it. We observed occasions where there were no staff available to support people to mobilise safely which put them at risk of falls. We observed that a member of activities staff had to support care staff to meet people’s needs, which took them away from providing activities and engagement for people.

The home was not decorated in a way that helped people living with dementia find their way around the building. We observed people finding it difficult to orientate themselves and requiring staff support to find their way to their bedroom or communal areas.

Staff told us they thought the training provided them with appropriate knowledge for the role. However, discussions with staff and observations meant we were not reassured staff were suitably knowledgeable.

Staff received regular supervision and appraisal. However, this was ineffective in identifying areas for improvement in staff practice.

There were safe recruitment procedures in place.

Medicines were managed and administered safely. However, some prescription creams were not stored securely.

People told us they knew how to make complaints and felt they would be acted upon.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.”

Further information is in the detailed findings below.

Brundall Care Home is currently registered to provide accommodation and support to a maximum of 40 people, including nursing care. However, the provider is currently amending their registration to remove the provision of nursing care and is only providing residential care. At the time of our inspection there were 11 people living in the home, none of whom required nursing care.

There was a registered manager in post. This person had previously held a senior position with the organisation and had become registered with CQC to manage Brundall Care Home in May 2016. A registered manager is a person who has registered with the Care Quality Commission (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.

When we inspected this service on 9 and 13 July 2105, we found that it was not meeting several requirements of the Health and Social 2008 (Regulated Activities) Regulations 2014. As a result of that inspection, the service was rated inadequate and placed in special measures.

We inspected the service again on 5 January 2016 and found that, although some improvements had been made, the provider was still in breach of the regulations for staffing, person-centred care, dignity and respect, the need for consent, safe care and treatment, meeting nutritional and hydration needs and good governance.

As a result of our inspection in January 2016, the service remained in special measures and we took action in line with our enforcement procedures.

The service was kept under review and the provider sent us an action plan in March 2016, which told us what changes and improvements were being made or were planned. The provider also sent us updated action plans and progress reports in April and May 2016.

Our inspection on 5 July 2016 found that significant improvements had been made in all areas and the provider was no longer in breach of the regulations.

Staff could demonstrate their understanding of keeping people safe and had completed effective training in safeguarding. Risks to people were being properly assessed and the actions required to minimise the identified risks helped to protect people and promote their freedom.

There were sufficient numbers of suitably trained and experienced staff on each shift and the use of agency staff was minimal. All staff demonstrated a good knowledge of, and communicated well with, the people they were supporting.

Staff had completed further training sessions since our previous inspection and the manager had systems in place to test staff’s competence and knowledge. This ensured the training had been effective. All staff had received formal supervisions and had their competency tested and observed on a regular basis. Appropriate recruitment procedures were being followed to make sure that new staff were safe to work with people who lived in the home.

Procedures for the safe management and administration of medicines were being followed and no errors or omissions were found in people’s medicine administration records.

The environment was clean and hygienic and had improved even further since our last inspection. Servicing and maintenance records were complete and up to date for the premises, as well as for portable and fixed equipment.

The service was ensuring that consent to care and treatment was sought in line with legislation and guidance and it was following the principles of the Mental Capacity Act (MCA) when making decisions on behalf of people lacking capacity.

People received care that was planned for each person as an individual. Where decisions needed to be made for people, these were made with as much input and involvement as possible from the person themselves. Where needed, ‘best interests’ decisions had been recorded and the processes followed appropriately.

People were consistently supported to eat and drink sufficient amounts and records of people’s intake were maintained when necessary. People were able to make choices at mealtimes, with staff support if needed.

Referrals to healthcare professionals were made in a timely way. Input, advice and guidance was also regularly sought from relevant professionals and acted upon appropriately.

People received their care in an unhurried, respectful and dignified manner. Staff respected people’s privacy and dignity and procedures were in place to protect people’s dignity, where they chose to have their bedroom doors open. People were supported to make choices and these were listened to and acted upon by staff. People were also encouraged to enhance or maintain their independence.

Some structured activities were available for people at various times during the week, although there appeared to be limited interim and informal activities during this inspection. The ‘resident of the day’ was encouraged to choose a particular event or pastime they would like to undertake.

People were able to voice their concerns or make a complaint if needed. Formal complaints were recorded appropriately, with information to show what action had been taken. People were also encouraged to record informal complaints or concerns.

A number of internal audits had been completed since our last inspection and the director’s audits continued to be carried out on a regular basis. These effectively identified any errors or omissions and any action that was required was recorded at the end of each audit.

Communication had improved significantly throughout the service since our last inspection. The registered manager was ‘hands on’, approachable and operated an open door policy. Staff and relatives’ meetings were held frequently, with an increased attendance level from relatives.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there were enough improvements to take the provider out of special measures.

Following this inspection, the overall rating for this service is ‘Good’. However, we will continue to monitor the service, to ensure that the improvements in the quality of the service are maintained.

Below is a summary of what we found. The summary describes the records we looked at and what people and staff told us to help us form our judgement. If you would like to see the evidence that supports the summary, please read the full report.

Is the service safe?

We looked at the care records of three people who were living at or had recently lived at Brundall. The records showed that care plans were in place which provided guidance to staff about how each person was to be supported. We saw that daily care reports and treatment records were up to date that recorded the personal care given each day. Body charts were frequently updated to show the treatment and changes to people's pressure ulcers.

Risk assessments were in place and these informed the risk reduction plans. They set out what action was required of staff to ensure that risks were managed.

Staff rotas showed that sufficient staff were employed to meet people's needs. There had been a high use of regular agency staff to meet the staffing levels required but new staff had been recruited and were taking up their roles at the time of this inspection. All staff were receiving training and supervision appropriate to their role. This meant that people received the care and support they needed to keep them safe.

There was a refurbishment plan in place which included upgrades for all areas of the home including people's own rooms. Work was taking place on plumbing and electrical systems to ensure that the premises were safe and fit for purpose.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care services. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

The care records showed that the service liaised with health and social care professionals appropriately. We noted that professionals were contacted when advice and guidance was required. GP, dietician and Speech and Language Therapists were consulted and there was evidence that any prescribed alterations to care were recorded and followed.

We saw that care records were reviewed each month or more frequently if necessary. Any changes to the care that people needed were clearly recorded within the person's care plan.

Is the service caring?

We were able to speak with one person, who told us, 'Staff are good.' We spoke with staff and they understood the specific needs of people living at the home. We observed the way staff interacted with people and saw that they were warm and friendly. Staff were attentive to people's needs and supported them to be as independent as possible.

Is the service responsive to people's needs?

The records we looked at showed that people's needs were assessed and care plans developed so that the risks to people were minimised. We saw that the service responded appropriately to the changing needs of people. We saw that where people did not wish to follow medical advice that this was clearly recorded and plans amended to try and reduce the risks this imposed.

People told us that they could spend their day where and how they wished. They confirmed that staff supported them to do so. They told us that their choices around daily living were respected.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you would like to see the evidence that supports our summary, please read the full report.

Is the service safe?

The staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the correct steps to take if they were concerned that abuse had taken place.

Equipment was well maintained and regularly serviced and all health and safety records were up-to-date. These checks meant that people were not placed at unnecessary risk.

We inspected the staff rotas which showed that there were sufficient staff on duty to meet people's needs throughout the day. However, visitors to the service commented that sometimes there were not enough staff on duty. One person said, "Most of the time there are enough staff but some days they are short." A person using the service told us, "They are usually around to help me." Another person stated that staff availability was, "Okay."

Staff personnel records contained all the information required by the Health and Social Care Act 2008. This meant the provider could demonstrate that the staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home.

We spoke with the manager about the Deprivation of Liberty Safeguards (DoLS). They told us they had been in contact with the local authority to enquire whether an application would be appropriate in respect of one person. This demonstrated to us that where there were concerns that appropriate action would be taken.

Is the service effective?

People we spoke with told us they were happy living in Brundall care home. When we asked one person if they were satisfied with their care and treatment, they indicated to us that they were, "Very satisfied.'

Staff explained how they communicated with people who were unable to communicate verbally and described how they supported people living with dementia. They were able to tell us about individuals' preferences, their health requirements, what things worried people and how they addressed their concerns.

Is the service caring?

The people and relatives we spoke with told us that staff treated them well and with care and consideration. One person said that their visitors were always warmly welcomed. People described the staff as caring and kind. One visitor said, "Staff are about and friendly. They chat and make you feel welcome."

We saw that people were supported by kind and attentive staff. Care workers were warm, friendly and respectful and they offered choices and encouragement to people. Staff had received training that was relevant to their role.

People told us they could spend their day where and with whom they pleased and staff assisted them to do this. One person spoke about preferring to spend their time in the garden, weather permitting and staff supported them to do this.

Is the service responsive?

Staff understood the diverse needs and preferences of the people living at the home and how they could be met. Residents and relatives meetings were held to seek the views of people using the service.

People knew how to make a complaint if they were unhappy. The complaints process was displayed on noticeboards in the home. The service was about to send out quality questionnaires to people and their relatives to ensure they were providing a quality service that met people's expectations.

People's needs were assessed and reviewed on a monthly basis. Where they changed we found that the service responded promptly and sought appropriate advice from health professionals when necessary.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Staff told us they were clear about their roles and responsibilities. They had a good understanding of the ethos of the home and were able to access training and development that enabled them to provide appropriate care and support. This helped to ensure that people received a good quality service at all times.

The service was developing a quality assurance system that would seek the views and opinions of people using the service and their relatives. This would enable the service to identify shortfalls and address them promptly, ensuring the quality of the service continually improved.