Brooke House

Brooke House is a residential care home providing personal and nursing care to up to 35 people. The service provides support to people mainly aged over 65 years, and many of the people were living with dementia. The service consists of a main house with bedrooms and shared facilities across 2 floors, with a people carrying lift, and then a ground floor unit joined to the main house, which supported people living with more advanced stages of dementia. At the time of our inspection there were 26 people using the service. The service was surrounded by spacious grounds offering people the opportunity to spend time outside.

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

From reviewing accidents and incident records, as well as medicine management records we identified examples of incidents which had not been reported to the local authority safeguarding team and to CQC, as required, to maintain people’s safety and welfare.

We identified risks within the care environment, where equipment needed to be replaced, changes were needed to reduce the risk of harm to skin from hot and uncovered surfaces and unsecured access to risk items, which placed people at risk of potential harm. This was of particular concern because many of the people at the service were living with dementia and relied on staff to maintain their safety.

Some areas of medicine management needed to be improved to ensure staff were working in line with local and nationally recognised best practice. We observed some people’s teeth and finger nails to be visibly dirty, their daily records indicated gaps in the completion of these basic care tasks.

Provider level auditing and oversight of the service, in the absence of a registered manager required some improvements, as areas of risk and shortfalls identified at this inspection had not been found as an outcome of their own audits and quality checks.

Inspection findings have resulted in breaches of the regulations and a recommendation being made to support improvement at the service. We found the provider team to be responsive to our feedback from the inspection, and they acted promptly to make changes and address risks to support improvement and safety at the service.

People were supported to engage with visitors, friends, and members of the local community to reduce the risk of social isolation. We observed there to be sufficient numbers of trained staff on shift to respond to people’s needs.

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

We observed caring and friendly interactions by staff and members of the management and provider team with people and their relatives. Members of the provider team were familiar with people’s needs and we observed they made time to meet with relatives and visitors during the inspection.

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 service was rated good at the last inspection (published 04 November 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service. There had also been some concerns brought to our attention relating to the management of people’s pressure care needs. A decision was made for us to inspect the service and examine those risks. This was a focussed inspection looking at safe and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate overall rating.

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 COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this report for further details. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Brooke House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to protecting people from the risk of harm or abuse and safe care and treatment. The service is required to have a registered manager, the lack of a registered manager also impacted on the rating given for well-led.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice:

The service is currently free from COVID-19. Staff were regularly tested for the presence of the virus and all, but two staff and people had received their vaccines. There was support in place to ensure staff and visitors were kept up to date and had enough knowledge of the correct use of personal protective equipment, (PPE) which was in plentiful supply. Staff spoken with were clear about the use and safe disposal of PPE.

Staff received infection control training and there was a infection control lead who played a key role in supporting staff. There were clear policies around infection control, PPE and donning and doffing procedures. The service had liaised with external agencies who had reviewed their infection control procedures, and these were good. In addition, management conducted their own audits and received top down management support.

The registered manager met regularly with her senior team and heads of department to help ensure they were clear about their roles and communication across the service was effective. Good communication was maintained with relatives, so they were clear about visiting and under what circumstances. The service had a conservatory which was protected by a two-way screen and could be booked by visitors to ensure they could maintain contact with their family member. This was cleaned after use and visitors were expected to wear PPE. The conservatory was accessed through a side door and not through the main house which reduced risks of cross infection.

Visitors to the main house was kept to a minimum and was open to health care professionals who were required to complete a trace and track form, have their temperatures taken and their oxygen levels checked. There was good signage around the use of PPE and reducing infection and there were hand washing stations. Cleaning records viewed demonstrated that regular cleaning took place.

Throughout our morning we saw evidence of people being engaged in appropriate activities and there was a robust plan to ensure people had opportunity to take part in activities which were appropriate to their needs. On the morning of inspection people were making bread and the service was full of nice smells. The service had a picture activity board, and photographs of people participating in activities.

We found the following examples of where good practice could be compromised:

The service was usually well staffed and regular staff provided continuity to people. Agency staff were kept to a minimum and on the day of inspection were only being used to support someone requiring one to one support. They were employed over a period of time and became a regular member of staff. On the day of inspection due to isolation the service were one domestic short. Although we identified good standards of hygiene and cleanliness, domestic staff were clearly under pressure to maintain high standards and to continuously clean the service, particularly frequent touch points. The housekeeper who acted as a domestic but also had additional areas of responsibility took great pride in the standards of cleanliness in the service but was not always able to complete all that was required. We raised with this the registered manager and suggested they risk assess the environment and decide what takes priority, for example, 'do all bedrooms needs to be cleaned every day'? Gaps in cleaning rotas were observed and there was some concern expressed by staff that cleaning did not always take place when the domestic staff were no longer on shift later in the day and evening.

We noted the conservatory used by visitors was also regularly used by staff to take their breaks. We did not observe this room being cleaned between staff use and would suggest staff either need to use another area or cleaning of this area should be stepped up.

Brooke House provides accommodation and support for up to 35 people who may be living with dementia, mental health support needs or with physical disabilities. At the time of this inspection there were 33 people living in the home. The service has an older unit in the main house, arranged over two floors with lift access between. The Brookefields unit is adjacent to the main home, is purpose built and on one floor.

There was a registered manager in post. 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. The registered manager was recently registered with CQC, completing the process in April 2017.

At our last inspection in August 2016. we did not identify any breaches of regulations. However, the safety and effectiveness of the service needed to improve. This included improvements in the way some medicines were managed, monitoring of pressure areas and in the timely completion of staff training. This included training for staff to understand their legal obligations when supporting people who might not be able to make specific, informed decisions.

At this inspection, we found that improvements had been made in the areas we highlighted last time. Some further improvement was needed to ensure the service people received was always as safe as it should be.

There was a new, electronic system for managing medicines. This tracked who had administered medicines, when, and provided a system for auditing, with daily reports. The registered manager could show they took prompt action to address any anomalies identified in the daily reports. The system was still bedding in but indicated improvements in the safe management of medicines. A concern was raised with us before our inspection, that sometimes people were without medicines because staff had not ordered it in a timely way. We found that the new system alerted staff to the need to reorder items and that people were unlikely to be left without essential medicines.

There were enough staff to support people safely. Robust recruitment processes and checks continued to protect people from the employment of staff not suitable to work in care. Staff were clear about their obligations to report any concerns should they suspect that people might be at risk of harm or abuse and people said they felt well treated by staff. However, a recent visit by the safeguarding and quality assurance team, highlighted two situations of concern. They considered that the registered manager should have shared these concerns with the local authority safeguarding team. The management team had taken action in relation to the safeguarding and quality assurance visit both to investigate and learn from the feedback they received.

During our inspection, we found a further example of an incident that should have triggered prompt discussion with the safeguarding team and further exploration. Between our two inspection visits, the management team acted on the concern that we raised. The registered manager and deputy manager had enrolled on further training specifically for the management of safeguarding concerns and possible abuse. They anticipated this would improve their awareness of issues that might indicate concern and require advice from safeguarding specialists.

Risks to people's safety and welfare were assessed and staff had guidance about minimising these. They were able to tell us what they did to promote people's safety and about their training to understand their obligations. The registered manager had made improvements to the timeliness with which staff completed their expected training. She had also sourced additional training for staff to help them in supporting people at risk of developing pressure ulcers. Staff felt this had improved their awareness of what to look for to ensure people's wellbeing and when to seek additional advice.

Staff were better prepared through training and additional guidance to understand their legal obligations when they supported people who may not be able to make decisions for themselves. The registered manager had also taken action to improve the day-to-day management of shifts by senior staff. This included providing clearer information about expectations and additional training in leadership.

People had a choice of enough to eat and drink to meet their needs. Staff monitored people at risk of not eating or drinking enough so they could seek professional advice about this aspect of people's health when they needed to. They also ensured people could access advice from other health professionals, such as their doctor and the district nursing team.

Staff had developed warm and caring relationships with people. We saw an example of people's dignity not being fully upheld during one mealtime. However, the registered manager took prompt action to improve people's experiences so this was not repeated when we checked again. She, and the operations manager, also agreed further action that would make sure staff could position themselves better and more easily, when the helped people to eat.

Staff understood people's needs and preferences, so that they could engage with people about what was important to them. They took people's hobbies and interests into account when they were both conversing with them or supporting people with activities.

People, with support from their relatives if they needed it, were given the opportunity to express their views and make decisions about their care. They were confident that, if they had concerns or complaints about their care, the registered manager would deal with them.

The registered manager and the provider had systems in place to ensure they monitored and checked the safety of the service, taking people's views into account. The registered manager and operations manager responded quickly and constructively to the issues that we raised. Their internal monitoring systems also showed where they identified improvements were needed and the action taken. This included arranging additional management training and support, as the registered manager was relatively new to her role.

Brooke House provides accommodation and support for up to 35 people who may be living with dementia, with mental health support needs or with physical disabilities. At the time of this inspection there were 34 people living in the home. The service is comprised of an older unit in the main house, arranged over two floors with lift access between. The Brookefields unit is adjacent to the main home, purpose built and on one floor.

There was a registered manager in post as required. 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.

Some improvements were needed to the safety of the service. Increased clarity was needed to the way that risks to people's skin integrity were managed and mitigated to promote people's safety. This included improving the application of external creams and lotions to protect and maintain the health of people's skin. The provider had already identified this as an issue. Staff were very busy and sometimes stretched to respond to people promptly. The registered manager was seeking an appropriate tool to use for assessing people's dependency levels to ensure that staffing levels remained safe as people's needs changed. Staff understood the importance of their role in contributing to protecting people from the risk of harm or abuse and of reporting any concerns they had. Recruitment practices contributed to people's safety.

There were some gaps in staff training which the manager was trying to address, chasing staff to complete some of their learning in a more timely manner. We found that there were also gaps in training for them to understand their legal obligations when they were supporting people who may not be able to make informed decisions about their care. This area needed to improve and the provider was aware of this. However, staff did understand the principles of trying to gain people's consent and cooperation. The registered manager understood what action they needed to take to ensure people's liberty was not unreasonably restricted in the interests of maintaining their safety.

People had enough to eat and drink to meet their needs. However, the quality of their mealtime experiences varied. There was not always a calm and conducive atmosphere for people to enjoy their meals. Where there were concerns about people's diet or other aspects of their health, staff made sure that they sought appropriate advice from health professionals.

Staff had developed warm and caring relationships with people using the service. They took action to offer reassurance and comfort when people became anxious or distressed. They also treated people with respect for their dignity and privacy and spoke with them politely. They offered people opportunities to make choices about their care. Staff considered how people communicated and how they could adapt what they did to ensure people were able to understand what was happening and make choices.

Staff had also developed a good understanding of people's backgrounds and histories so they knew what was important to them. They took these and people's interests into account in people's opportunities to pursue activities and hobbies as well as in the way that they delivered their care.

People were supported to express their views about their care so that improvements and changes in the service were made if it was needed. They were confident that, if they had concerns or complaints, the management team would listen to them and take their concerns seriously. Staff were also supported to express their views and found both the registered manager and deputy manager supportive if they had issues or suggestions to make.

The registered manager and the provider's representatives had systems in place for checking and monitoring the quality of the service people received. These systems were effective in identifying what improvements were needed and had already identified the improvements we considered necessary. However, we found that these improvements did not result in breaches of regulations and were confident that the management team would address them.

As part of this inspection we spoke with five people who used the service, the registered manager, a senior manager who represented the provider, and three members of staff. We also reviewed records relating to the management of the service which included four care plans, daily records, staff records and quality assurance monitoring records.

Below is a summary of what we found. The summary describes what people using the service, relatives and 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.

This is a summary of what we found:

Is the service safe?

People told us they felt safe living at Brooke House and would be able to speak with a staff member if they were concerned about anything. The service had guidance for staff in protecting people from abuse and we found that staff members had a clear understanding of their responsibilities in this area.

Risk assessments for care needs were completed and provided appropriate actions for the identified risk to be reduced. Applications had been appropriately made in regard to Deprivation of Liberty Safeguards for people whose liberty was restricted. Staff members and the manager showed they had appropriate knowledge regarding recent guidance.

People using the service said there were enough staff available to meet their needs. Information from staff members, the manager and records shows that there were enough staff available with the skills and training to care for people appropriately.

Is the service effective?

People told us that staff members helped them with everything they needed assistance with. They told us that they were satisfied with the care they received. Care records provided clear and detailed information about people's care needs and preferences. We found that staff members had a good understanding of people's care needs and of current good practice in dementia care.

Health needs were responded to and people had access to health care professionals if they needed this. Care records contained information and guidance from the health care professionals involved with people's care.

Is the service caring?

People said that staff members were polite and kind; they respected people's privacy and dignity, and involved them in their care. Staff members knew people's care needs and their personal preferences when we spoke with them.

We observed interactions between people and staff members and we found that the members of staff were patient and understanding of people's individual needs. There was a warm, friendly atmosphere at the home. Staff members spent time with people and ensured they had the care and attention they needed. They spent time with people during activities and made sure that those who were less able to participate easily were provided with a positive experience.

Is the service responsive?

We saw that people's individual physical and mental support, care and treatment needs were assessed and planned for. Their individual choices and preferences regarding their support and care were valued and respected.

Is the service well led?

There had been an annual survey to gather the views of people using the service a year ago and a further survey was due to be sent out. Responses from the last survey were positive, but actions were identified for suggests that had been made. There were other systems in place to monitor and assess the quality of the service provided, and the service had analysed this information for any trends or themes resulting from complaints, accidents or incidents.

One person said, "They (the staff) look after me really well." Another person we spoke with said, "The food here is really nice, we always have a choice at lunchtimes and the staff are so helpful." A further person we spoke with told us, "I really like it here, there is so much space and the gardens outside are lovely."

We looked at a range of records including care records, staff recruitment and training records, maintenance records and medication records. These records were stored securely, readily available, accurate and fit for purpose and provided us with evidence that the service was maintaining the information we required.

Staff received appropriate support and training to carry out their duties.

People who used the service told us that the care and support they received was good. One person told us that they were very, "Happy and had nothing to complain about." Another person told us that staff made sure that they, "Have my newspaper to read everyday."

People who used the service were all living with dementia and did not therefore comment on their care plans. We observed staff during the inspection. They treated people with respect, played games with them and spoke in appropriate terms.