Archived: Hothfield Manor Acquired Brain Injury Centre

Hothfield Manor Acquired Brain Injury Centre is registered as a care home with nursing and as a rehabilitation service for 32 older people, younger adults and people with physical adaptive needs.

The service was in two parts. People staying in the Neurological Rehabilitation Unit (NRU) were usually admitted directly from hospital after treatment for traumatic head injuries or strokes. They generally stayed for 12 weeks when they worked intensively on developing their independence with support from nurses, physiotherapists, occupational therapists, psychologists and technicians. There was also a speech and language therapist. The NRU was run by the lead nurse.

People living in The Manor stayed for longer and some had made it their home. Others continued to progress their recovery from brain injuries with the intention of moving on. The Manor was run by the care lead.

There was a team of rehabilitation assistants who worked in both parts of the service. They provided people with practical assistance including washing and dressing and promoting continence.

In this inspection report when applicable we refer collectively to nurses, rehabilitation professionals, rehabilitation assistants and technicians as being, ‘staff’.

The two parts of the service were self-contained each having lounges, shared use bathrooms and toilets and bedrooms.

There were 28 people living in the service at the time of our inspection visit.

People's experience of using the service and what we found

People and their relatives were positive about the service. A person staying in the NRU said, “I think the service is very good. It’s a shock to need to be here but I’m glad I’m getting the help I need to get better.” In a thank-you card to the service a person who had stayed in the NRU said, A really big thank-you to everyone for your patience, encouragement, nursing skills helping in so many ways, it was really appreciated. Without my time at Hothfield Manor I would not be in such good health and strength as I am today (and be able to leave early also)!

People had not always been supported to use medicines safely. However, robust steps had been taken to reduce the risk of further mistakes being made. We have made a recommendation about the safe management of medicines.

People were safeguarded from the risk of abuse. People received safe care, treatment and rehabilitation from nurses, rehabilitation professionals and rehabilitation assistants who had the knowledge and skills they needed.

There were enough staff on duty and safe recruitment practices were in place. Accidents and near misses had been analysed so lessons could be learned to help avoid preventable accidents. Hygiene was promoted to prevent and control infection and people had been helped to quickly receive medical attention when necessary.

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

The accommodation was designed, adapted and maintained to meet people’s needs and expectations.

Equality and diversity were promoted. People were treated with kindness and compassion and their right to privacy was respected.

People were consulted about their rehabilitation and care. They had been given information in a user-friendly way and supported to avoid the risk of social isolation. There were robust arrangements to resolve and learn from complaints. The service did not provide end of life care.

Quality checks had been completed and people had been consulted about the development of the service. Good team work was encouraged and joint working was promoted.

For more details, please read 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 8 September 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Hothfield Manor Acquired Brain Injury Centre is registered to provide accommodation with personal and nursing care for up to 45 adults with an acquired brain injury. The service is divided into three areas. The Neuro-Rehabilitation Unit (NRU) provides short term specific rehabilitation; the Manor House provides long term care; and seven Bungalows, which are not currently in use. The provider has said that they don’t plan to re use them at the moment, not at least until they have been refurbished. At the time of the inspection there were 17 people living at the service. 13 in the Manor House and four in the NRU.

People were living with a range of care and nursing needs, some people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff. People's bedrooms were provided over two floors, with a passenger lift in-between. There were sitting/dining rooms on the ground and first floors. On the ground floor there was also a hydrotherapy pool, a gym and an adapted daily living skills kitchen. Outside there was an enclosed garden and large grounds which people could access.

At this inspection, records, both electronic and paper, were in good order and contained current information that was clearly laid out; making them easy to use. Risks had been properly assessed and environmental checks had been completed in line with current guidance.

The service had a registered manager who was present throughout the 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 and associated Regulations about how the service is run.

Medicines were managed safely and people received their medicines when they should. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and referrals were made when required. People were supported in a safe environment and risks had been identified, and were managed in a way that enabled and encouraged people to live as independent a life as possible.

Staff understood how to protect people from the risk of abuse. They had received safeguarding training and were aware of how to recognise and report safeguarding concerns. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the provider or outside agencies if needed.

Equipment and the premises received regular checks and servicing in order to ensure it was safe. The registered manager monitored incidents and accidents to make sure the care provided was safe. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do.

A robust system to recruit new staff was in place; this helped to make sure that people were supported by staff that were fit to do so. Throughout the day and night there were sufficient numbers of staff on duty to meet people’s assessed needs. When staff first started to work at the service they were supported to complete an induction programme. Staff continued to be supported with ongoing training, support and supervision. Staff meetings took place. These all gave opportunity for staff to share ideas and discuss any issues.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Systems were in place to check if people were at risk of being deprived of their liberty, to obtain consent from people and to comply with the MCA. People were supported to make decisions and choices about all aspects of their lives.

Staff encouraged people to be involved and feel included in their environment. People were offered activities and participated in social activities when they chose to do so. Staff knew people and their support needs well. The care and support needs of each person were different, and each person’s care plan was personal to them. People had detailed care plans, risk assessments and guidance in place to help staff to support them in an individual way.

Staff were caring, kind and respected people’s privacy and dignity. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff.

People were encouraged to eat and drink enough and were offered choices around their meals and hydration needs. Staff understood people’s likes and dislikes and dietary requirements and promoted people to eat a healthy diet.

Staff told us that the service was well led and that they felt supported by the registered manager to make sure they could support and care for people safely and effectively. Staff said they could go to the registered manager at any time and they would be listened to and suggestions discussed.

Feedback was sought from people, relatives and professionals. Complaints had been documented and recorded. People and relatives said they knew how to complain if necessary and that the registered manager was approachable. Quality assurance audits were carried out to identify any shortfalls within the service and how the service could improve. The registered manager had good management oversight and was able to assist us in all aspects of our inspection.

Hothfield Manor Acquired Brain Injury Centre provides accommodation with personal and nursing care for up to 45 adults with an acquired brain injury. The service is divided into three areas. The Neuro-Rehabilitation Unit provides short term specific rehabilitation; the Manor House provides long term care; and seven Bungalows, which are not currently in use. At the time of the inspection there were 21 people living at the service.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff. People's bedrooms were provided over two floors, with a passenger lift in-between. There were sitting/dining rooms on the ground and first floors. On the ground floor there was also a gym and an adapted daily living skills kitchen. There was a swimming pool, which was not in use due to on-going repairs. Outside there was an enclosed garden and large grounds which people could access.

The service had a newly appointed registered manager who was available on the days of the 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.

Hothfield Manor was last inspected on 29 and 30 December 2015.They were rated as inadequate overall at that inspection and placed into Special Measures. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that significant improvements had been made in most areas. In others, however, there were still some improvements required.

People's safety was not always protected due to safety checks not being routinely undertaken. Equipment was serviced at required intervals.

People enjoyed the food however we found people's weight, and hydration needs were not being monitored effectively, placing people at risk of not receiving sufficient amounts to eat and drink. People had access to healthcare services however, a lack of effective recording meant advice was sometimes not followed through by staff.

Risks to people and guidance for staff were not always recorded accurately. People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. Staff knew about whistle blowing and were confident they could raise any concerns with the provider or outside agencies if needed.

Feedback, in the form of quality surveys was not sought from people, their relatives or professionals. This meant that opportunities to improve the service could be missed.

Electronic records were not easily accessible, or consistently recorded. Audits took place but were not always effective in identifying shortfalls or required actions.

People did not always receive support that met their needs. The care and support needs of each person were different, and each person’s care plan was personal to them. People had detailed care plans, risk assessments and guidance in place to help staff to support them in an individual way.

Medicines were well managed. Staff followed correct and appropriate procedures in the storage and administration of medicines.

There were enough staff deployed to meet people's needs and they had received appropriate training and supervision to help them carry out their roles effectively. Staff were caring and responsive to people's needs and interactions between staff and people were warm and respectful. Recruitment processes had been followed to ensure staff were suitable for their jobs.

Staff had completed induction training when they started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people’s needs. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people’s care and lives.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some people at the service had been assessed as lacking mental capacity to make complex decisions about their care and welfare. At the time of the inspection the registered manager had applied for DoLS authorisations for people who were at risk of having their liberty restricted.

Staff encouraged people to be involved and feel included in their environment. People were offered varied activities and participated in social activities of their choice. Staff knew people and their support needs well. Staff were caring, kind and respected people’s privacy and dignity. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff.

Staff were clear about their roles and were positive about the registered manager and support from the organisation. Staff were proud of the improvements that had been achieved and we found a more open, transparent culture amongst staff and management. Audits and checks were in place but were not always effective in identifying shortfalls or areas for improvement.

As this service is no longer rated as inadequate, it will be taken out of special measures. Although we acknowledge that this is an improving service, there are still areas which need to be addressed to ensure people's health, safety and well-being is protected. We identified a number of continued breaches of Regulations. We will continue to monitor Hothfield Manor to check that improvements continue and are sustained.

We found a number of 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 this report.

This inspection was carried out by one Inspector over two hours. During the visit we talked with the manger about the changes that had been put in place for medicines storage, and the changes that were due to be implemented. We also talked with five staff, and two people living in the service.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We saw that the premises were visibly clean and satisfactorily maintained. We viewed the three areas where medicines were stored, and saw that medicines were stored safely. In the Manor House, the staff had noticed that the room temperature where medicines were stored sometimes rose higher than 25 degrees Centigrade. This meant that that some medicines could become less effective if they were not always stored at the correct temperatures. The staff had arranged for the medicines trolley to be stored temporarily in the Neuro-Rehabilitation Unit clinical room at these times, to protect the medicines. This showed that staff were aware of the importance of safe storage.

Is the service effective?

We viewed the processes for receipt and disposal of medicines, and the records for administration. These demonstrated that medicines were correctly checked in, and were administered to people in accordance with their prescriptions.

The company had recognised that auditing procedures for medicines needed to include an assessment of safe storage, and they were reviewing auditing processes.

Is the service caring?

Medicines’ records showed that people were given prescribed medicines correctly. We saw that pain assessment charts were used to remind staff of the people who might be experiencing pain, and to offer them pain relief as needed. Some people had ‘as necessary’ (PRN) medicines. We saw that clear directions were given for administering these medicines, and the reasons were clearly recorded.

People who were making significant progress with managing their own care were assessed for their ability to manage their own medicines. This showed that staff enabled people to be as independent as possible and to take increased responsibility for their own treatment.

Is the service responsive?

The service ensured that people’s medicines were reviewed by their GP or other suitable health professionals on a regular basis. People who were experiencing difficulties in their behaviour were referred to the mental health team for re-assessment, including a review of their medicines.

Is the service well-led?

The manager informed us that the company which owned the service had recognised that their monthly auditing processes for medicines management did not include medicines’ storage. The company were in the process of reviewing this documentation.

The manager told us that improvements in storage in two of the units had not yet been implemented. This showed a disappointing time delay, but we saw purchase orders and installation orders for the work that was to be done to improve the storage facilities. The manager had contacted us prior to this inspection to inform us of the company’s action plan for improved storage; and had told us that the service was waiting to hear from the estates manager for a date when the work would be carried out.

The service had processes in place to take people’s views into account, and to take action as a result of their comments.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We found the service was not always safe because although medication administration was managed appropriately, medication storage was unsatisfactory in each of the three units, and required improvement.

We saw that the centre had reliable assessment processes in place prior to admitting new people. Care plans contained comprehensive details to instruct the staff in the individual care that people needed. They included risk assessments for maintaining people’s safety and security.

People who lacked the mental capacity to make decisions about where they lived or the care that they needed had been appropriately supported by their family members or advocates, and by health and social care professionals, to make decisions on their behalf and in their best interests. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). One person currently had a Deprivation of Liberty Safeguard authorisation put in place. Applications had been made on behalf of other people living in the centre as necessary.

Is the service effective?

We found that people's care needs were thoroughly assessed, and reflected the individual care that people needed. The home provided a good variety of different types of equipment that enabled people to develop their physical and co-ordination skills, and assisted them to become more independent.

We found that health professionals providing health care had specific knowledge about their areas of work, and were able to support people in making progress with their health needs. The staff recognised people's changing health needs, and were quick to make referrals to additional health staff if the person's condition indicated this was appropriate.

Two people in the Neuro-Rehabilitation Unit were able to tell us that they had made significant progress with their health needs since their admission, and were really pleased about this. Relatives that we spoke to said that "There is a clear focus on rehabilitation, and X has done very well since moving in here.”

We saw that people were assisted as necessary in maintaining an adequate food and fluid intake. This included medical intervention using "PEG" feeding; and staff assisting people to eat and drink where they needed support.

We saw that the service provided the different levels of health care, rehabilitation and support that people needed at different stages of their recovery and development. This showed that the service was effective in the support it provided.

Is the service caring?

People we spoke with said that the staff were very helpful and kind. They said that the staff answered their call bells promptly and their requests for help. One person said that when they rang their call bell that the staff would arrive quickly and say “What can I do to help?” Another person said: “They look after me fine”. We observed that staff spoke to people in a gentle and caring manner and did not rush them.

The centre provided a wide range of activities for people to take part in. This included subjects which helped people to regain their independence, such as preparing drinks and meals, and managing their laundry. Other activities included leisure pursuits such as a gardening club, quizzes and film afternoons, and going out of the centre. Each person in the Manor House unit was enabled to go out of the centre with staff support at least once per week. This included shopping trips, and visits to places such as the beach, and the local attraction of Leeds Castle.

Is the service responsive?

We looked at six people's care plans and saw that they were reviewed and amended in line with people's changing needs.

We saw that the home provided people with different types of activities according to their abilities, their health needs and their preferences.

People receiving care said that if they raised any concerns they were confident that appropriate action would be taken.

We looked at staff training records and saw that the staff received mandatory training in relevant subjects and were able to take further training if it was in line with their job roles.

Staff said that they felt well supported by each other and worked well as teams. They met together in the units for regular meetings so as to discuss people’s ongoing needs and ensure their care and support was suitable for their individual needs.

Is the service well-led?

The manager was not present on the day of the inspection, but we saw that the deputy manager was well known by the staff and people living in the home. He provided leadership for the staff and took part in practical skills and meeting people’s care needs, as well as carrying out other management duties.

We found that the centre had processes in place for obtaining people’s views. This included the use of questionnaires, and residents’ meetings.

The deputy manager told us that the manager and staff carried out monthly audits which were sent to the company’s head office for quality control checks. These included care plan audits, medication audits, health and safety and environmental audits and an infection control audit. We viewed some of the medication audits and saw that these had been carried out in accordance with the questions on the audit. However, the auditing processes had failed to identify the unsuitable storage for medication in each area of the centre, showing that the auditing processes were not fully effective. Staff in each unit said that they had verbally raised their concerns about the medicines’ storage but “Nothing had been done”. This showed that staff views were not always taken into account and followed through on their concerns.

People were protected from the risk of abuse. The manager described some concerns and the action planned and taken to protect people.

People benefitted from safe and comfortable accommodation. People told us “The place here and the surroundings are really lovely.” We saw that each area of accommodation was suitable for the differing needs of people who used the service. The Neuro-Rehabilitation Unit contained a number of dedicated therapy areas for people to use.

People who used the service and their relatives were asked for their views about the care provided and these were acted on. People told us “There is nothing but good to say” and “I’ve got no complaints about anyone.”

People were cared for by staff who were supported by supervision to deliver care safely and to an appropriate standard. However, not all staff had completed all of the training they needed to meet people’s needs effectively.