Smallbrook Care Home

People’s experience of using this service:

The management and leadership of the service had improved since our last inspection. The home had a new management team, which had improved the support provided to staff and communication with people and their families.

Regular residents’ and relatives’ meetings had been introduced to keep people up-to-date with developments at the home and to ask for their feedback. Any suggestions people made had been listened to and actioned.

Staff at all levels met regularly to ensure they were providing people’s care in a safe and consistent way. Staff were encouraged to give their views about how the service could be improved and to raise any concerns they had. The management team maintained an effective oversight of the service, which ensured people’s care was well-planned and managed. Key aspects of the service, such as medicines management and infection control, were audited regularly.

The way in which risks were managed had improved. A falls protocol had been introduced to ensure that all potential contributory factors were analysed for people who were at risk of falling. There was clear guidance for staff about how to support people who displayed behaviours that challenged the service in a consistent way. Adverse events, such as accidents or complaints, were analysed and discussed with staff to ensure that learning took place and improvements were made.

There were enough staff on each shift to keep people safe and meet their needs. People were supported to maintain good health and to access healthcare services when they needed them. Staff worked well with other professionals to ensure people’s needs were met.

Staff were kind and caring and treated people with respect. They encouraged people to make choices about their care and respected their decisions.

Staff received the training they needed for their roles and had access to management support through supervision and appraisal. Staff shared information effectively to ensure people received care that reflected their needs.

People had access to a range of activities and events and had opportunities to access their local community. People’s friends and families could visit whenever they wished and were encouraged to be involved in the life of the home.

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.

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

At the last inspection on 6 March 2018 the service was rated Requires Improvement. The report of this inspection was published on 17 April 2018.

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

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

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Smallbrook Care Home 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.

Smallbrook Care Home accommodates up to 41 people across two floors, each of which have separate adapted facilities. The home provides a service to people living with dementia and all people living at the home had a diagnosis of dementia. Some people also had physical disabilities and long term medical conditions. At the time of our visit, there were 24 people living at the home.

The registered manager had very recently left and the provider was in the process of recruiting a new 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.

Risks to people were routinely assessed and plans were implemented to keep people safe. Where people had suffered falls, the provider had taken actions to reduce the risk of them falling again. There were systems in place to analyse repeated falls and regularly review risks. People had plans in place to support them with needs relating to their behaviour and staff had been trained in how to support people living with dementia. Staff had the right knowledge in relation to safeguarding and understood their roles in protecting people. People had access to a variety of activities and care was planned in a person-centred way. However, we did identify some areas, such as end of life care, where information was not complete. We made a recommendation about care planning.

Staff supported people to access healthcare professionals when required and we saw evidence of their involvement in care planning. People received their medicines safely and in line with best practice. People’s dietary needs were met and where people had needs relating to their nutrition, care plans were followed in this area. The home environment was clean and the provider carried out regular checks to reduce the risk of the spread of infection. We did note one sluice area that was not completely clean and secure. We made a recommendation about how the provider manages their sluice areas.

The provider was developing a positive culture through visible leadership at the home. There had been changes to the whole management team at the time of inspection and planned improvements in response to our concerns had been implemented. There was increased management presence at the home and staff said they felt supported. The provider carried out a selection of regular audits to check the quality of the care that people received. There had been a number of complaints due to the poor quality of care delivered at our last inspection. The provider was working on addressing these at the time of our visit. We recommended that the provider improves the information given to complainants.

People were supported by kind and committed staff. We observed pleasant interactions between people and staff throughout the inspection. Staff provided sensitive care to people and communicated with people in a way that was sensitive to their needs. People were regularly offered choices and involved in their care. Staff knew people well and supported them in a way that enabled them to maintain independence. Staff were respectful and provided care to people in a way that maintained their privacy. Staff sought people’s consent and where they were not able to, staff followed the guidance of the Mental Capacity Act 2005. There were enough staff working at the home to keep people safe and the provider had carried out appropriate checks on new staff to ensure they were suitable for their roles.

Smallbrook Care Home is a care home providing support to up to 41 people who are living with dementia. The home specialises in supporting people living with dementia and there is a unit for people living with early onset dementia. This unit supports people who are under 65 and have been diagnosed with dementia. At the time of our inspection the home was providing support to 35 people.

There was a registered manager in post but they were on planned leave at the time of 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.

Our last inspection was in April 2017 where we identified one breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found that the provider had not taken enough action to resolve this breach of regulation. We also identified a further nine breaches of regulation. We found that the provider was in breach of regulations 9, 10, 11, 12, 17, 18, 19 and 20 and 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We will be requesting information from the provider about specific incidents involving people to ensure that there had been no instances of avoidable harm.

People did not receive safe care. Responses to incidents were not robust which meant that where people had suffered falls, the underlying risks were not managed causing incidents to occur again. The provider was not always proactive in identifying risks and staff were not clear on how to manage individual risks to people. We also identified that important information was missing from medicines records and safe medicines management practices were not always followed.

There were not enough staff at the home to safely meet people’s needs. After the inspection, the provider increased staffing levels in response to our findings. However, the provider will need to ensure they are able to calculate staffing numbers based on people’s needs. There was information missing from one staff file which showed that recruitment checks were not always robust enough to ensure that people were supported by safe staff. The provider took action following our inspection and assessed the risks relating to the missing information from this staff file, however this had not been done proactively.

At our inspection in April 2017, staff were not always raising safeguarding incidents with management. At this inspection we found that incidents were being reported to management and to the local safeguarding team. However, staff were not clear on where they could raise safeguarding concerns outside of the organisation so the requirements of this regulation had not been met.

Staff lacked the training to meet the complex needs of the people that they supported. As a specialist care home for people living with dementia, people’s needs often required specialist interventions from staff. We found evidence that staff lacked this specialist training and did not respond appropriately to people’s behavioural needs.

People’s legal rights were not protected because staff did not follow the guidance of the Mental Capacity Act (2005). Where restrictions were placed upon people, the correct legal process was not followed. Staff and management lacked an understanding of how to apply restrictions in line with the Mental Capacity Act (2005).

Care lacked personalisation and was not always provided in a way that reflected people’s needs and preferences. We saw instances where staff failed to promote people’s dignity when providing care. People’s dietary needs were met but we noted this was not always done in line with people’s routines and preferences. There was a lack of choice on offer for people.

There was a lack of leadership and governance at the home. The registered manager was on planned leave at the time of inspection. The arrangements for management cover had not worked and an assistant manager had left. There was a lack of support and coaching for staff and this was reflected in the care that they provided. Auditing systems were not robust enough to identify the concerns that we found on the day of inspection. Where improvements had been identified through audits, these had not always been actioned. The provider had also failed to notify CQC of important incidents and events.

People had access to a range of activities and we observed people and staff interaction positively. Staff respected people’s privacy when providing support. Relatives knew how to complain and the provider kept a record of complaints but did not identify patterns and themes. We recommended that the provider reviews their systems for analysing complaints.

You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

On the day of inspection we met 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.

The inspection was unannounced and took place on 12 April 2017.

People felt safe living at Smallbrook Care Home. Despite this staff had not acted to protect people in a timely manner when a safeguarding concern was raised and put people at risk.

Recruitment checks on agency staff had not been followed appropriately. This also meant that agency staff had not been given information about people they were supporting..

Since concerns were raised the registered manager had implemented an action plan that focused on the reporting of safeguarding and the employment of agency staff.

Staff had received training and had the knowledge to spot signs of abuse and act appropriately to report it. The registered manager has implemented a robust agency checklist and induction. This measure safeguards people as the registered manager is now checking that agency workers recruited safely. It also ensures agency staff have the knowledge needed to support people appropriately.

On the day of inspection we met 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.

The inspection was unannounced and took place on 19th September 2016.

The requirements of the Mental Capacity Act (MCA) were not always being fully met. The registered manager had submitted Deprivation of Liberty Safeguard applications but the restrictions in place were not the least restrictive for many people. The registered manager was aware of how the restrictions impacted on people’s freedom and had a plan in place to address this immediately. We have recommended that the home works in line with the MCA (2005) to ensure all restrictions are appropriate.

Staff did not have regular supervisions with their line manager. This shortfall was being addressed and despite this lack of supervision the staff felt supported by management.

Relatives said that Smallbrook Care Home was a safe place for their loved ones to live.

People were protected from harm. Staff had the training and the knowledge to understand risk, and reported accidents and incidents in a timely manner. Staff understood how to report suspected abuse so that action could be taken if necessary. Incidents and accidents were investigated and the manager reviewed reports to prevent them from re-occurring. Any potential risks to individual people had been identified and appropriately managed. People had risk assessments that staff followed to minimise risk and keep people safe.

Risk assessments had been completed to ensure the home was safe for people to live in and there were arrangements in place should there be an emergency. People were supported by sufficient numbers of staff who were recruited safely and had the skills and knowledge to support people.

People received medicines in a safe way. Staff had a good understanding of the medicines they were administering medicines were stored and disposed of appropriately.

Staff had the knowledge and skills to support people with dementia and physical needs. Training was available to staff, which included training courses related to people’s needs.

People’s nutritional needs were met and people had a varied diet. Staff ensured that people had enough to eat and drink. Staff ensured people were supported to maintain their health and wellbeing and people received support from healthcare professionals when required.

People were cared for by staff who put them at the centre of all they did. People were not rushed by staff and were treated with dignity and respect. People were encouraged to maintain relationships with their family and those that mattered to them.

People’s care met their needs and wishes. Staff were responsive to the needs and wishes of people. People were encouraged to be involved in how the home was run and people and relatives felt comfortable in raising a concern or making a complaint.

The home was led by a registered manager who was a positive role model. Organisational values of providing a ‘secure, relaxed and homely environment, where individuality is emphasised and care needs and wellbeing is of the prime importance’ was reflected in the support given by staff and the management team.

Quality assurance systems were in place to monitor the quality of the service being provided and the running of the home. People and staff were involved in the running of the service. Feedback from people, relatives and staff was used by the registered manager to improve service delivery.