Eastbrook House

Eastbrook House 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. Eastbrook House accommodates up to a maximum of 43 people in one adapted building. At the time of this inspection there was 39 people living at the service.

There was a registered manager in post at the time of this inspection. However, the registered manager was away on annual leave. 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 last inspection on 27 and 28 September 2016 the service, although rated ’Good’ overall, was found to be in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The management and administration of medicines was not safe. There was incomplete recording and monitoring of people’s food and fluid intake and re-positioning charts for people at risk of malnutrition and pressure sores.

Following the last inspection in September 2016, we asked the provider to complete an action plan to show what they would do and by when to improve each of the key questions to at least good. At this inspection we found that the provider had made significant improvements to ensure the safe administration of medicines. Re-positioning charts were comprehensively completed as required. However, we identified concerns relating to the lack of meal choices people were offered especially at lunch time and we found very little improvement in the way in which food and fluid charts were completed and monitored to ensure people who were at risk of malnutrition and dehydration were supported appropriately.

At the last inspection we found that people were not given a choice of what they would like to eat especially for those people living with dementia who may not have known what was on the menu and may not have been able to request an alternative. During this inspection we found little improvement had taken place especially after the last inspection the registered manager had assured us that improvements in this area would be implemented. Following the inspection the registered manager sent us information in relation to the improvements they had implemented following this inspection.

Fluid charts were put in place to monitor people’s fluid intake where this was an identified need. However, we found that these were not completed comprehensively to fully monitor people’s intake and take appropriate action where poor fluid intake was noted. However, we saw that people were appropriately hydrated and always had access to a variety of hot and cold drinks.

Care staff continued to demonstrate a clear and in-depth understanding of abuse, how to recognise signs of abuse and the steps they would take to ensure people were protected and kept safe and free from abuse.

Risk assessments continued to identify and assess risks associated with people’s health, care and support needs. Guidance and information was available to all staff on how to reduce or mitigate all assessed risks so that people were kept safe and free from harm.

We observed sufficient numbers of staff available to appropriately support people with their health, care and social needs. However, staff that we spoke to felt that due to additional tasks allocated to them in the absence of laundry and kitchen staff, this impacted on their workload and ability to appropriately care and support people.

We observed people to have access to a variety of drinks and snacks to support their hydration and nutrition needs. On the first day of the inspection, people were observed enjoying their food and were seen to eat well. However, on the second day of the inspection, we observed people not to eat so well and a large amount of waste returned to the kitchen. We saw that food had not been presented well and people did not seem to like the taste of the meal that they had been given.

The provider continued to follow robust recruitment practises to ensure that only staff assessed as safe to work with vulnerable adults were recruited.

All staff demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA), Deprivation of Liberty Safeguards (DoLS). Records confirmed that people, where possible, had consented to the care and support that they received and where people were not able to make such decisions, relatives had been involved in the decision-making process.

Care staff continued to be supported through on-going training, regular supervision and annual appraisals to enable them to carry out their role effectively.

Care plans were detailed and person centred which gave specific information and guidance to care staff on how to meet people’s identified needs and wishes. We saw that care staff knew the people they supported very well.

We observed people and relatives had established positive and caring relationships with care staff who knew them and their relatives very well and supported not only the person but their relative as well.

The provider had displayed their complaints policy which detailed guidance on how people and relatives could lodge a complaint. People and their relatives knew who to speak with if they had any concerns or issues to raise.

The provider had a number of processes in place to monitor and oversee the quality of care that was provided to people. However, the provider did not robustly follow their own governance systems as the inspection process highlighted issues that the service should have identified and addressed themselves. We have made a recommendation about ensuring robust and complete governance systems are adhered.

There was a registered manager 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.

At our last inspection in June 2015 we found that some aspects of medicines management were not safe. The provider had not submitted any applications, where relevant, for a Deprivation of Liberty Safeguard (DoLS) authorisation and accurate records had not been kept in relation to people’s care and treatment. These resulted in breaches of Regulation 12, 13 and 17 of the Health and Social Care Act 2008.

Due to the serious nature of the breach of Regulation 12, relating to unsafe medicine management, we had taken enforcement action against the provider. We issued a warning notice to the provider detailing the issues we found and requiring them to become compliant within a specified timescale. An unannounced focused inspection took place in August 2015 to check that this significant breach of legal requirements had been addressed. During the inspection it was found that all legal requirements for medicines had been met.

During this inspection we again found there to be some aspects of medicines management that were not safe. Care staff were not signing the Medicine Administration Record (MAR), once a medicine had been administered to confirm that the person had received their medicines. We also found two examples of where people had not been given a particular medicine for a number of days due to poor communication and poor management of medicines.

Risks associated with people’s care and support needs had been identified and these had been assessed, giving staff instructions and directions on how to safely manage those risks. However, where records were needed to be kept in relation to monitoring food and fluid intake and turning charts to monitor people’s skin integrity, these had not been completed to ensure that these areas were safely monitored and that people were protected from those identified risks.

We found the home to be clean and tidy. However, on the second day of the inspection we noted a significant odour originating from the main lounge on the ground floor. We highlighted this to the registered manager who told us that they would address the issue.

Systems were in place which monitored the quality of service provision with a view to making improvements. It was positive to note that the provider had identified some of the same issues as identified as part of this inspection. However, the provider had not recorded what actions had been taken as a result of identifying the issues and had not put in place improvement plans to minimise re-occurrence.

People told us that they felt safe and were happy with the care that they received at Eastbrook House. Care staff were aware of what constituted abuse and the actions they would take if abuse was suspected.

The provider ensured that safe recruitment practices were observed which included obtaining criminal record checks from the disclosure and barring service, previous employment history and references from previous employment confirming past conduct especially when working with vulnerable adults.

Food looked appetising and the chef was aware of any special diets people required either as a result of a clinical need or a cultural preference. People and relatives spoke positively about the food at the home. However, we found that people, especially those living with dementia were not offered any meal choices.

Care plans were specific to each person and their needs. These were detailed and person centred. People’s likes and dislikes and care preferences had been noted.

Senior managers, head of care and care staff demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered manager had submitted applications to the local safeguarding authority for each person who required an authorisation to ensure that people were legally being deprived of their liberty which was in their best interest.

Care staff enjoyed working at the home and were positive about their experiences and the support that they received from the registered manager and their colleagues. Staff confirmed that they received regular training which enabled them to care for people with effectively. Care staff received regular supervision and had also gone through their annual appraisal with the registered manager.

We spoke with a number of professionals during the inspection and also obtained feedback from local commissioners and health professionals. Feedback received was positive and no concerns were noted in relation to the care and support people received.

At this inspection we found breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to people receiving safe care and treatment and the safe management of medicines. You can see what action we told the provider to take at the back of the full version of the report.

The focus of the inspection was to gather evidence to help us answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

As part of this inspection we also looked at compliance actions that we had made during our inspection of Eastbrook House on 15 January 2014. During the inspection in January 2014, we were concerned that the provider had failed to ensure that people always experienced care, treatment and support that met their needs and protected their rights because information about people's needs and risks were not always documented in their care plan. We were also concerned that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

During our inspection on 29 April 2014, we saw that the provider had taken appropriate steps to ensure that information about people's needs and risks were documented in their care plan and that that they had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

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 want to see the evidence that supports our summary please read the full report.

Is the service safe?

People who used the service told us that they felt safe in the home. One person said 'I feel safe in this home and do not feel restricted here'. People said that they felt comfortable in the home and that members of staff treated them with respect and dignity.

Safeguarding procedures were comprehensive. When we discussed safeguarding with staff, they were aware of the signs of abuse and the action to take when responding to allegations or incidents of abuse.

The Care Quality Commission monitors arrangements related to the Deprivation of Liberty Safeguards (DoLS), which applies to care homes. The registered manager told us that no applications for deprivation of liberty had needed to be submitted. However, we saw that some people living in the home needed continuous supervision and control. Saff told us that due to risk to their safety people were not free to leave without staff or family members accompanying them. This may mean that deprivation of liberty authorisations were required. The registered manager agreed that they would contact the local authority with regard to this issue.

Some staff we spoke with did not have an understanding of the Mental Capacity Act 2005 (MCA) and DoLS. We noted that all staff had not yet received this training. The Registered Manager confirmed that they would ensure that staff attended these courses.

We saw evidence that people were protected from the risks of inadequate nutrition and hydration. We saw that the provider monitored people's weight appropriately and ensured that people were supported to eat and drink sufficient amounts to meet their needs.

Staff we spoke with told us that generally there were sufficient numbers of staff on duty to meet people's needs. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Is the service effective?

People told us that they were happy with the care they received at the home and felt that their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well.

People's care needs were assessed and we saw evidence of this in the care files we looked at. We noted that since our inspection on 15 January 2014, the provider had introduced a new format of care plans which ensured that people's needs had been assessed and care and treatment were planned and delivered in line with their individual care plan. Risk assessments had been carried out where necessary and there was evidence that these had been reviewed recently.

During our inspection on 15 January 2014, we saw that care plans did not all include useful information about people such as their previous occupation, likes and dislikes. During our inspection on 29 April 2014, we found that the care plans included information about people's preferences and life history.

Is the service caring?

One person told us 'Staff are friendly and helpful' and another said 'It is like a community here. There is a very relaxed atmosphere here'. People we spoke with said that they had been treated with respect and dignity in the home. People also said that staff were friendly and spoke with them in a respectful manner.

We saw that there was good interaction between members of staff and people who used the service.

People who used the service and relatives we spoke with were very positive about the staff at the home. One person said that the staff were 'caring' and 'were always willing to help'

People looked well cared for and we saw that the atmosphere was relaxed in the home.

Is the service responsive?

All the people we spoke with who used the service said that they felt comfortable raising queries and concerns with the Registered Manager and members of staff. One relative said that staff always listened to suggestions and acted on them and did their best to resolve issues.

The home had a complaints policy and procedure and had feedback forms available for people to leave their comments and suggestions.

All relatives we spoke with said that staff kept them informed of developments and communication was very good at the home.

Is the service well-led?

During our inspection on 15 January 2014, we found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. We were concerned that the monitoring of people's risk assessments was not consistent and that care plan audits failed to pick up on this and were therefore not effective.

During our inspection on 29 April 2014, we saw that the provider had implemented a new format of monthly care plan audits.

People who used the service and their relatives were asked for their views about the care and treatment provided. They told us that they felt listened to and were happy with the quality of care provided.

Staff told us that staff meetings enabled them to raise queries and concerns with their team and share information. Staff also told us that they felt able to consult the Registered Manager if they had concerns or queries.

Management in the home completed regular audits and we were able to view health and safety, fire risk and environmental risk audits.

We noted that the last resident's meeting was held in October 2013. The provider acknowledged that this should be held more frequently.

People and their relatives were positive about the service and the staff who supported them. One relative feedback to us 'I cannot fault the care given to my mother. The staff are very thoughtful and caring in every way. It feels like one big family. I know my Mum is happy here even though she can't say so.'

Throughout the inspection we observed staff involving people in decisions about their care and respecting their preferences. One person with dementia told us 'they are kind and treat you with respect but not in a condescending way.'

The care and treatment plan for people with dementia was based on their initial assessment of needs and involved a number of healthcare professionals including doctors, nurses, occupational therapists and physiotherapists. However, people's care plans were not always being completed in sufficient detail to ensure staff were aware of all the care needs of each person or the potential risks to their safety.

People with dementia and their relatives told us they were satisfied with the way the home met their health and social care needs. Records we saw indicated that people had good access to dentists, opticians and chiropodists on a regular basis. We saw that people were able to access social work support as well as access advocacy services.

Staff told us that there was very good communication between themselves and that they worked well together.

The service had a number of quality assurance initiatives to ensure that the quality of care provision was monitored and included the views of people with dementia and their relatives. However, the service was not always ensuring risks to people's safety were assessed, disseminated to staff or reviewed on a regular basis.

The provider had systems in place to ensure medications were handled and administered safely. We spoke with three people who use the service and a health professional about their medications. People were positive about how staff administered their medications.

We also reviewed the recruitment processes. We looked at three staff files and the home's recruitment policy. Evidence from staff files showed that appropriate checks were in place before care staff commenced working with people who use the service.

There were systems in place to ensure that people were protected from abuse and to ensure they received the care they needed. People told us they felt safe at the home.

Staff were supported and there were quality monitoring systems in place.