Brockholes Brow - Preston

About the service

Brockholes Brow - Preston (Brockholes Brow) is a small community for adults who live with deafness, learning disabilities and mental health needs. The service is registered to provide a combination of accommodation and personal care for up to 34 people. The service comprises of four linked houses with some single occupancy bedrooms and a self-contained flat which can be used as shared accommodation. The service is also registered to provide personal care to people in their own homes. There were 28 people using the residential service and 11 people using the domiciliary care service at the time of our inspection.

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

This service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right Support

People and their relatives told us they felt safe and protected from the risk of abuse and avoidable harm by staff who understood how to recognise, respond and report concerns. The registered manager had improved safeguarding processes. However, improvements were required to ensure staff were encouraged and supported to share concerns about poor practices within and outside the service. While we noted improvements in risk management, people were not adequately protected from the potential risk of avoidable harm such as skin damage and fire risk. People’s medicines were not safely managed. People were supported by staff who had been safely recruited. Staff had received training and guidance in the prevention and control of infections including COVID-19 however infection prevention practices exposed people to infections.

Right Care

People did not receive care that supported their needs and aspirations was focused on their quality of life, and followed best practice. Care records were not always complete or written in a way that promoted outcome focused care. People told us they were supported people to access the local community however there was limited opportunities to take part in meaningful day time activities. People's individual communication needs had been assessed and staff had tools to assist their interactions with people. However, people shared concerns that some staff were not able to communicate with them. The registered manager had made improvements in the way they dealt with people's concerns and complaints.

The provider had made improvements to the governance arrangements, leadership structure and the quality monitoring system. This had contributed to some of the improvements we observed at the service. However, the changes were in their infancy and had not been adequately imbedded. We found shortfalls linked to the implementation of changes. Changes required had not been sufficiently expediated to improve shortfalls identified at the last inspection in April 2021. This included person centred care planning and practices, rectifying shortfalls timely and medicines management. There was a lack of monitoring on the care delivered to people living in their own homes. Staff shared mixed responses regarding the leadership, support and the culture in the service.

Right culture

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. While people's care and support had been planned in partnership with them where possible and some improvements had been made in relation to mental capacity, practices in the service did not always maximise choice and control. The provider had supported staff to acquire training in various areas. This was a significant improvement. Further improvements had been made to support people in line with national and best practice guidance.

The provider had started to review the way care was provided and their care model. However, we found little improvements had been made since our last inspection. The campus style model of service delivery offered to people at this setting does not meet current best practice. It is known that in large campus style environments that truly person-centred care which promotes people having meaningful lives where they have control, choice and independence is difficult to achieve. Care practices were not person centred to reduce the impact.

People and their relatives shared mixed comments regarding the caring nature of the staff team. Some people told us staff were kind and considerate and treated them with dignity. However, some people said staff did not support them to be as independent as they could be to fully exercise their choices.

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 11 June 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made in some areas of care delivery however the provider was in continued breach of regulations.

At our last inspection we also recommended that the provider seek guidance on end of life care practices. At this inspection we found the provider had not sufficiently acted on the recommendations or made improvements needed.

This service has been in Special Measures since 11 June 2021. The overall rating for this service is ‘Requires improvement’. The service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well-led sections of this full report.

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 coronavirus and other infection outbreaks effectively.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold register providers to account where it is necessary for us to do so.

We have identified breaches of regulation in relation to keeping people safe from preventable harm such as skin damage, medicines management, infection prevention and control. The provider was also not supporting the delivery of person-centred care and maintaining good governance at this inspection.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Brockholes Brow - Preston (Brockholes Brow) is a small community for adults who live with deafness, learning disabilities and mental health needs. The service is registered to provide a combination of accommodation and personal care for up to 34 people. The service comprises of four linked houses with shared and some single occupancy. The service is also registered to provide personal care to people in their own homes. There were 27 people using the residential service and 10 people using the domiciliary care service at the time of our inspection.

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

People told us they felt safe and staff were kind and caring. However, our observations and findings showed that people did not always receive safe care and treatment. While safeguarding protocols were in place, they had not always been followed to report repeated falls and repeated incidents of self-harm. Risks to people were not adequately assessed and reviewed or used to make effective decisions on people’s care. People at risk of unintentional weight loss had not been adequately monitored to reduce deterioration. People were not supported by suitably qualified staff to reduce risks of harm. Some parts of the premises were in a state of disrepair and infection prevention practices had not been adequately implemented in line with COVID-19 guidance. We were not assured by measures in place. The provider had not followed national COVID-19 guidance to facilitate people to receive family visitors. We observed people received their medicines safely. However, we found shortfalls in medicines management practices and record-keeping.

People were not always supported by staff who had the right skills and knowledge. Staff and the registered manager had not received training to meet the specialist needs of people they supported. People were not always supported to have maximum choice and control of their lives and staff had not always supported them in the least restrictive way possible and in their best interests. The policies and systems in the service did not always support the provision of care in the least restrictive practices and there was a lack of awareness on promoting decision making. People told us staff sought their preferences and referred them to advocates. Staff supported people to have access to health professionals and specialist support, however this was not consistent. Improvements were required to ensure people offered a variety of choice on their daily meals.

Right support:

¿ Model of care and setting maximises people’s choice, control and independence

Right care:

¿ Care is person-centred and promotes people’s dignity, privacy and human rights

Right culture:

¿ Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

This service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

The campus style model of service delivery offered to people at this setting does not meet current best practice. It is known that in large campus style environments that truly person-centred care which promotes people having meaningful lives where they have control, choice and independence is difficult to achieve. How the provider can modernise the service will be discussed following this inspection.

People told us staff were kind and caring and we observed some caring interactions between staff and people. However, practices in the service needed to be improved to ensure people were treated with dignity and their human rights were respected. Staff worked in partnership with people and their advocates.

The service was not well-led. There was a lack of oversight from the registered manager on the running of the service, in addition there was a lack of oversight on the running of the service from the provider who are the Board of Trustees. The registered provider needed to ensure there was skilful leadership to maintain regulatory oversight and monitor people’s experiences and outcomes. The registered provider and the registered manager had not established a robust governance and quality monitoring system to continuously check and improve the safety of the care and people’s experiences. The arrangements did not ensure the care model was reviewed in line with current models of care to promote a person-centred approach and the delivery of safe and high-quality care. Shortfalls were identified but not always resolved in a timely manner. Leadership in the home had established community links with local health and social care services.

People’s care was not always designed in a person-centred manner as a result of the care model. People had been admitted away from their local counties against best practice guidance. People’s care and experiences had not been adequately reviewed as a result. Care records were written in a person-centred manner; however, they did not always accurately reflect people’s current needs and risks. Staff had not received training in supporting people towards the end of their life. We made a recommendation about end of life care. The provider had not adequately followed national COVID-19 guidance in relation to ensuring people could receive visitors in the home. People knew how to make a complaint, however improvements were required to ensure responses were person-centred and showed awareness of people’s rights.

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 17 September 2018).

Why we inspected

We received concerns in relation to health and safety arrangements at the service and the infection prevention and control practices linked to prevention of COVID-19. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with infection prevention and control measures to prevent the spread of COVID-19, so we widened the scope of the inspection to become a comprehensive inspection which included all the key questions we inspect against.

We have found evidence that the provider needs to make improvements. Please see the safe, effective responsive and well-led sections of this report.

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 coronavirus and other infection outbreaks effectively.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold register providers to account where it is necessary for us to do so.

We have identified breaches of regulation in relation to keeping people safe from preventable harm such as falls, unintentional weight loss, monitoring clinical risks and safeguarding. The provider was also not meeting legal requirements in relation to seeking consent, responding to changes in people’s needs, delivery of person-centred care, deploying suitably qualified staff and good governance at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the registered provider to understand what they will do to improve the standards of quality and safety. We will work alongside the registered provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the registered provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the registered provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the registered provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

The last inspection of this service took place in August 2016 when we found the provider was not meeting the requirements of Regulation 9 : Person-centred care of the Health and Social Care Act (Regulated Activities) Regulations 2014. This was because people and their representatives were not always involved in reviews of their care. The service had also failed to notify us of the events as required by law. The service had been rated as Requires Improvement and submitted an action plan to demonstrate how they would address these shortfalls.

Brockholes Brow - Preston (Brockholes Brow) provides accommodation for up to 34 people who are deaf and have a range of learning disabilities, physical disabilities, and/or mental health problems. There are four separate houses, one being for people needing intensive one to one care. All rooms are of single occupancy and there is a communal lounge, kitchen and dining room in each of the four houses.

The home had a newly appointed manager who had applied for registration with CQC to be the registered manager. 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.

We checked the action plan sent in after the last inspection and found that the service was now meeting the regulations.

Plans of care were based around the individual preferences of people as well as their medical needs. We saw how people and their representatives were involved in reviews of their care, to ensure it was of a good standard and meeting the person's needs.

Staff were kind and caring and treated people with respect. We observed many positive and caring interactions throughout the inspection. Staff knew people's likes and dislikes which helped them provide individualised care for people.

The provider used a robust recruitment procedure which ensured people received support from staff vetted as suitable to work with vulnerable people. People were involved and contributed to the recruitment process of potential staff. All staff used British Sign Language (BSL) and deaf staff were recruited as much as possible to act as positive role models. This had included the recent appointment of the new manager. Staff were skilled in communications including BSL, to maximise engagement with people.

A number of new staff had recently started work and the senior management team had under gone a restructure. Staff and people in the home told us they were feeling very positive about these changes.

People were safe living at the home because they were supported by a sufficient number of staff who had the right skills and knowledge to meet their needs. Staff understood their responsibilities with regard to reporting suspected abuse, in order to safeguard people.

The service had ensured risks to individuals had been assessed and measures put in place to minimise such risks. A comprehensive plan was in place in case of emergencies which included detail about how each person should be supported in the event of an evacuation.

Staff received induction and on-going training to enable them to meet the needs of people they supported effectively. Staff were supported by way of regular supervision, appraisal and access to management.

Effective systems were in place to ensure people's medicines were managed safely. Only trained staff were allowed to administer medicines.

We have made a recommendation that the provider ensures that the records for administration of 'as and when' medications (PRN) include written protocols for their use.

People’s rights were protected. The registered manager was knowledgeable about their responsibilities under the Mental Capacity Act 2005. People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made to do so.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s healthcare needs were well managed by the service. Staff worked as part of multi-disciplinary teams to support people with a range of complex healthcare needs. People were very well supported to access external healthcare services as they required. The new manager was very focused on ensuring equal access to health services.

People had access to a wide range of activities which were provided seven days a week and were well supported by staff to access the community and activities further afield.

The service was being well-led and run by the new manager, senior staff and executive team who had a clear vision about promoting deaf people to have opportunities to achieve and engage fully in society.

The last inspection of this service took place on 11 June 2014, when we found the provider was not meeting the requirements of the regulations with regard to Records, but was meeting the requirements of all other regulations we inspected against. We inspected again on 19 November 2014 and found sufficient improvements had been made with regard to Records.

Brockholes Brow provides accommodation for up to 34 people who are D/deaf and have a range of learning disabilities, physical disabilities, and/or mental health problems. All rooms are of single occupancy and there is a communal lounge, kitchen and dining room in each of the four houses. The service is located on the outskirts of Preston city centre, with easy access to the motorway network, public transport links and a range of amenities. Ample car parking spaces are also available within the grounds of the home.

The home had a registered manager, however they had been on extended leave at the time of our inspection. 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.

Plans of care were based around the individual preferences of people as well as their medical needs. However, people and their representatives were not always involved in reviews of their care, to ensure it was of a good standard and meeting the person's needs. This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were systems to assess, monitor and improve the quality of service provision. However, in the absence of the registered manager, these had not been operated effectively. The provider had employed a dedicated member of staff to oversee quality assurance. On the second day of our inspection, they had implemented systems around auditing and notifications which gave us assurances the quality of the service would be assessed and monitored effectively. The lack of statutory notifications regarding significant events at the service was in breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Staffing levels at the home appeared adequate to meet people's needs at the time of our inspection. However, staff commented that they felt stretched to deliver meaningful activities for people, because of sickness absence among staff. We have made a recommendation about this.

People were safe living at the home because they were supported by a sufficient number of staff who had the right skills and knowledge to meet their needs. Staff understood their responsibilities with regard to reporting suspected abuse, in order to safeguard people.

The service followed safe recruitment practices to ensure only suitable candidates were employed to work with people who lived at the home.

The service had ensured risks to individuals had been assessed and measures put in place to minimise such risks. A comprehensive plan was in place in case of emergencies which included detail about how each person should be supported in the event of an evacuation.

Staff received induction and on-going training to enable them to meet the needs of people they supported effectively. Staff were supported by way of regular supervision, appraisal and access to management. However, senior staff had not been receiving regular supervision since the registered manager began their period of sick leave.

Effective systems were in place to ensure people's medicines were managed safely. Only trained staff were allowed to administer medicines.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005) and the associated Deprivation of Liberty Safeguards.

People were supported to eat and drink enough to maintain their health. People could access external healthcare services as they required and were supported to do so.

People had access to a wide range of activities which were provided seven days a week and were supported to access the community and activities further afield. However, recent problems with staff sickness had impacted the level of support people received.

Staff were kind and caring and treated people with respect. We witnessed many positive and caring interactions throughout or inspection. Staff knew people's likes and dislikes which helped them provide individualised care for people.

During this inspection we checked a random sample of people's records, staff supervision and appraisal records, the business continuity plan and a random selection of risk assessments and service records. We found the records we looked at were accurate and up to date. Records were kept securely and could be located promptly when requested.

Below is a summary of what we found. The summary is based on our observations during the inspection. We visited the home, spoke with people who used the service - via a British Sign Language interpreter - and looked at records. We also spoke with staff employed by the service. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

We found that people who used the service and their relatives had been fully involved in decisions made around their care.

People we spoke with said they felt safe and well looked after.

We found that safeguarding procedures were in place and staff understood how to protect people they supported. Staff we spoke with had a good understanding of safeguarding procedures for vulnerable adults.

Staff felt well supported by the manager and senior staff and were confident in reporting any concerns.

Is the service effective?

The health and care needs of those who used the service had been thoroughly assessed.

We saw from records that regular contact had been maintained with other health and social care professionals in order to provide safe and effective care.

People we spoke with had been involved in the preparation and review of care plans.

Is the Service caring?

We spoke with people who used the service. We asked about the care they received. All of the feedback given to us was positive. People told us staff were caring and they were happy.

Staff we spoke with told us they enjoyed their job and they felt well supported by management.

We observed caring interactions between staff and people who used the service throughout the inspection.

We looked at care files for people who used the service and found that information was recorded in a person centred way in some places. However, parts of care plans were written in the first and third person, which was inconsistent. Some support plans did not contain sufficient detail in guidance for staff to deal with certain circumstances.

Is the service responsive?

People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

We observed that staff responded to people well, by anticipating their needs appropriately. Care plans contained a description of people's likes and dislikes.

People were able to raise concerns with staff and felt they would be listened to and acted on appropriately.

Is the service well-led?

The service worked well with other professionals to make sure people received care in a joined up way.

The manager held regular meetings with people who used the service and staff.

Checks and audits were carried out. The resulting actions to address any identified shortfalls were not recorded.

The provider had implemented an appropriate complaints policy.

Some records were not accurate and up to date. The registered manager was not able to provide some of the records we asked to see during the inspection.

We identified a minor concern in relation to care and welfare, which made this outcome area none compliant with Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The plans of care and the delivery of support were not always individualised. There was a lack of personalised guidance for staff to follow regarding supporting people with challenging behaviour. Clear guidance would promote a more consistent approach. Some arrangements did not promote person centred care and support. There was no guidance provided for staff about the management of some prescribed medications. Individual guidance would help to promote consistency of use and ensure medication was given when needed. The current arrangements did not always ensure that medication was administered as prescribed. Together these areas created the potential for people to not consistently receive the care, treatment and support they needed.

Comments received from those living at Deafway included:

"(Name removed) helps me a lot. He is my keyworker. We get on very well."

"On Sunday I go to the gym. It is fine here."

"I work four days a week mowing the lawns in the grounds. I get paid and I'm saving up."

During our inspection we assessed standards relating to care and welfare and how people were supported to give consent to care and treatment provided. We also looked at how they were safeguarded from abuse. Standards relating to recruitment of staff and monitoring the quality of service provision were also inspected. We did not identify any concerns in any of the outcome areas we assessed.

A relative told us 'This is a fantastic place'.

Whist comments from residents included:

'The staff are quite bright they talk to us and look after us'.

'The staff help me'.

'If there's anything I need I let the staff know and it happens'.

Staff we spoke with told us:

'One thing I've really liked is to assess the level of care for clients and this is one of the best jobs'.

'We've just had big management change'I think personally for the good, always good to have someone new ideas, fresh approach'.