Archived: Brackenfield Hall

Updated 19 December 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 23 October 2017 and was unannounced. The inspection team consisted of two adult social care inspectors and two experts by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

At the time of our inspection there were 59 people using the service. During the inspection we spoke with 13 people who used the service and nine visiting relatives. We spoke with the area manager, registered manager, deputy manager, one senior care assistant, one head of housekeeping, two domestic assistants, the cook and one kitchen assistant. We also spoke to two visiting health and social care professionals.

To help us understand the experience of people who could not talk with us we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us evaluate the quality of interactions that took place between people living in the home and the staff who supported them.

We spent time observing daily life in the home including the care and support being offered to people.

We looked at documentation relating to people who used the service, staff and the management of the service. This included three people’s care records, three staff records, and the systems in place for the management of medicines and quality assurance.

Prior to the inspection we gathered information from a number of sources. We reviewed the information we held about the service, which included correspondence we had received and notifications submitted to us by the service. A notification should be sent to CQC every time a significant incident has taken place, for example where a person who uses the service experiences a serious injury.

We asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. The PIR was completed and returned as requested.

We contacted staff at Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. They had one documented review in the last 12 months which gave positive feedback about the quality of care and reporting of incidents.

We gathered information from the local authority’s contracts team who also undertake periodic visits to the home. They gave us feedback from their recent visit which took place in October 2017.

This information was considered as part of our judgements made about the service.

Updated 19 December 2017

Brackenfield Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Brackenfield Hall is registered to provide accommodation and personal care to a maximum of 60 older people, some of whom may be living with dementia. The service is provided over three floors; the first two floors are split into four units. Two units on the first floor and one unit on the ground floor support people living with dementia. The second floor level is used for the kitchen, laundry and staff area. At the time of our inspection there were 59 people living at the service.

Our last inspection at Brackenfield Hall took place on 2 August 2016. The home was rated Requires Improvement overall. We found the service was in breach of four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. The registered provider sent us an action plan detailing how they were going to make improvements. At this inspection we checked the improvements the registered provider had made. We found sufficient improvements had been made to meet the requirements of these regulations.

We carried out this inspection on 23 October 2017. The inspection was unannounced. This meant the home’s staff and management did not know the inspection was going to take place.

At the time of our inspection the home had a registered manager in post. A registered manager is a person who has registered with the 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.

People spoken with were very positive about their experience of living at Brackenfield Hall. They told us they were happy, felt safe and were respected.

Whilst staff told us they were provided with regular supervision, we found staff supervisions were not always recorded. Since this inspection the registered provider submitted an updated supervision matrix. This showed all staff had received regular supervision or were due to receive supervision.

We found systems were in place to make sure people received their medicines safely so their health needs were met. Medicine protocols were in place to guide staff when to administer medicines prescribed on an ‘as and when’ basis to meet people’s health needs.

Staff recruitment procedures were in place. The registered provider ensured pre-employment checks were carried out prior to new staff commencing employment to make sure they were safe to employ.

Staff were provided with relevant training, which gave them the skills they needed to undertake their role.

Sufficient numbers of staff were provided to meet people’s needs. We saw staff responded in a timely way when people required assistance.

People’s care records contained detailed information and reflected the care and support being given.

The service provided a programme of activities to suit people’s preferences. We observed activities taking place and feedback from people who used the service was positive.

Staff knew people well and positive, caring relationships had been developed. People were encouraged to express their views and they were involved in decisions about their care. People’s privacy and dignity was respected and promoted. Staff understood how to support people in a sensitive way.

There were systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to.

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