Brandon House Nursing Home

Brandon House is a residential care home providing personal and nursing care up to a maximum of 35 people. The service provides support to older people living with dementia. At the time of our inspection there were 30 people using the service. Accommodation is spread over two floors.

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

Quality assurance checks had not always identified areas needing improvement. For example, we found improvements were needed in regards to medicine management, including storage as well as environmental risks linked to infection prevention and control. The provider took the necessary steps to address areas of improvement we found either on the day of our inspection visit or immediately following this.

People’s care records were not always sufficiently detailed to show risks associated with people's care were effectively managed and responded to in a timely way to keep people safe. There were sufficient numbers of staff to support people’s needs and staff were recruited safely. Staff felt supported by the management team. People and their relatives spoke positively of their experiences of the service. Relatives spoken with felt their family members were safe living at Brandon House.

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 30 January 2019).

Why we inspected

We received concerns in relation to the management of nutrition and care. As a result, we undertook a focused inspection to review the key questions of Safe and Well led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report. The provider responded to our findings by taking immediate actions to mitigate any immediate risks that could impact on people’s care.

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

Enforcement

We are mindful of the impact of 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 monitor the service and will take further action if needed.

We have identified a breach in relation to Regulation 17 at this inspection.

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.

Brandon House is operated by HC-One Limited; a large provider of care homes. Brandon House provides nursing care and accommodation for up to 35 people. The majority of people who live at the home are older people living with physical frailty due to complex health conditions and / or dementia. The home offers end of life care to people. At the time of our visit there were 30 people living in the home.

People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in post. 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.

At our last inspection in February 2018 we rated the service as Requires Improvement. This was because in two out of the five key areas we checked, we found improvements were required. At this inspection, we found improvements had been made and further improvements were planned for. The area of Safe continues to be rated Requires Improvement, however, the overall rating has changed to Good.

Overall, medicines were handled safely. However, during our inspection visit a staff member did not consistently follow the provider’s policy for safe administration of medicines.

Staff understood their responsibilities to protect people from the risks of abuse and told us they would share any concerns they had following the provider’s safeguarding policies. The registered manager understood and followed their legal responsibilities when safeguarding concerns were identified to them by staff or through checks made. The provider checked staff’s suitability to deliver care and support during the recruitment process.

People were protected from the risks of cross infection and the home was clean and tidy. Individual risk management plans were in place for staff to follow and staff knew what action to take in the event of an emergency.

People were supported by trained staff, who overall, followed the provider’s policies and training given to them. People felt staff had the appropriate levels of skill, experience and support to meet their care and support needs.

People were supported to eat a balanced diet and encouraged to eat and drink enough to maintain their wellbeing. Staff supported people to access support from external healthcare professionals to maintain and promote their health.

Staff had received training in the Mental Capacity Act 2005 and worked within the principles of the Act. Managers understood their responsibilities under the Act and when ‘best interests’ meetings should take place.

Staff supported people with kindness and in a caring way to meet their physical care and support needs. People’s privacy and dignity was respected.

People had individual plans of care which provided staff with the information they needed. There were numerous activities offered to people, however, these took place largely on the ground floor of the home. There was ‘work in progress’ by the provider to look at how communal space could be increased on the first-floor.

Staff were happy in their job role and felt supported by the registered manager through meetings.

People and their relatives had no current complaints about the service. Concerns and complaints raised were investigated by the provider.

The provider, the area director and registered manager checked the quality of the service to make sure people’s needs were met. There was recognition that some improvements, such as timely record keeping, needed to be embedded into the service. Audits had identified where improvements were needed and these had either been acted on or were ‘work in progress.’ The provider, area director and registered manager understood their regulatory responsibilities and with other organisations and healthcare professionals to ensure positive outcomes for people who lived at the home.

At the last inspection on 31 May 2017, the service was rated as requires improvement. This was because we found there were not always enough staff to keep people safe and respond to their needs. Risk management plans and the actions taken to manage risks were not consistently recorded. We found the mealtime experience was not positive for everyone and improvements were needed in providing people with opportunities to go out into the local community. Staff did not always feel valued and sometimes lacked confidence in their role. Audit systems had not identified these concerns.

This inspection visit was a comprehensive inspection and during this inspection we checked to make sure improvements had been made. Improvements had been made to the effectiveness and responsiveness of the service and these are now rated ‘Good’. However, some improvements were still needed in their audit systems because they had not identified some of the improvements we found in the safety of the service.

Brandon House Nursing Home is a care home registered to provide nursing and personal care to a maximum of 35 people. People in care homes receive accommodation and nursing and/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. At the time of our inspection visit, 32 people lived at the home. Seven of those people were living in the home on a 'discharge to assess' basis. Those people would be in the home for a short period prior to discharge to a more suitable place of care.

The home has accommodation over two floors with communal lounges on both floors and a dining room on the ground floor.

A requirement of the service’s registration is that they have a 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 and the associated Regulations about how the service is run. There was a registered manager in post.

People told us they felt safe at the home. Staff had received training so they understood what might constitute abuse and the action they should take to safeguard people if they had any concerns. Accidents and incidents that had impacted on people’s safety had been referred to the local authority safeguarding team and had been investigated. The provider’s recruitment policy ensured, as far as possible, that staff were safe to work in a care environment.

On the day of our visit there were enough staff to keep people safe and respond to their requests for assistance. However, staff told us they often worked without the full complement of staff which meant they could not always be so responsive. An identified staffing need between 8.00pm and 10.00pm was not being filled at the time of our visit.

The provider used a range of recognised risk assessment tools to identify potential risks to people’s health and wellbeing. Improvements were needed when staff recorded the actions they had taken to manage identified risks. Staff supported people to mobilise and transfer around the home safely and where people had fallen, appropriate action had been taken to minimise the risk of further falls.

Staff received training to meet people’s needs, and effectively used their skills and knowledge to support people and build relationships. Staff understood their roles and responsibilities in relation to infection control and hygiene.

Staff were responsive to changes in people’s health needs. They understood how to manage people’s specific healthcare needs and when to seek professional advice and support so people’s health was maintained. People received their medicines as prescribed.

Although staff found it difficult to articulate their understanding of the Mental Capacity Act 2005, overall they worked within the principles of the legislation. They sought people’s consent and respected the decisions they made. Where restrictions on people’s liberty had been identified, applications to deprive them of their liberty had been submitted to the authorising authority.

People were supported to eat and drink enough to maintain a balanced diet. Staff knew about people’s nutritional needs and monitored their weight and appetite.

The provider assessed people's needs before they moved to the home to ensure they could provide effective support and care. The views of people and their relatives were taken into account when people’s care was planned.

Staff told us they liked working at Brandon House and worked well with other staff in ensuring people received the care they required. Staff took time to understand people’s needs and communicated effectively with them. Interactions between people and staff were kind and compassionate and staff respected people’s privacy.

People were offered activities and social opportunities and this was being developed so it included people’s areas of interest and individual hobbies.

Staff and people had opportunities to share their views about the service and felt more confident they would be listened to. The provider and registered manager were developing their focus on improvement and learning.

Brandon House Nursing Home provides dementia nursing care for a maximum of 35 people. On the day of our visit there were 31 people living in the home. The home has two floors each with its own communal and dining area.

A registered manager was in post. 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.

During our last inspection undertaken on 12 November 2014 we found inconsistencies in people’s records regarding their mental capacity. During this visit improvements had been made and this meant the provider was meeting the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Consent to care was sought in line with legislation and guidance. Mental capacity assessments had been completed and where people had been assessed as not having capacity, best interest decision meetings had taken place and the outcomes were clearly recorded.

People toId us they felt safe living at Brandon House Nursing Home. However, people’s family members and the staff felt on occasions there were not enough staff available to keep people as safe as possible.

Procedures were in place to protect people from harm. Staff had a good understanding of what constituted abuse and staff refreshed their knowledge by completing safeguarding training. Risks associated with people’s care were identified. Detailed information for staff to follow to reduce risks and to keep people safe when delivering care was not always consistently recorded.

Some people were at risk of dehydration or malnutrition. However, we could not be sure those people had received sufficient nutritional intake as quantities being consumed were not being accurately recorded.

There were processes to keep people safe in the event of an emergency. Incident and accident forms were completed. Information was analysed and action was taken to reduce the likelihood of the incidents happening again.

People’s family members spoke positively about the way their relation’s medicines were administered by the trained staff.

The provider's recruitment procedures minimised, as far as possible, the risks to people’s safety. New staff members received effective support when they first started working at the home and staff received regular training which supported them in meeting the needs of people living in the home effectively.

Staff had their work performance monitored through one - one meetings with their manager. Staff had opportunities to attend and contribute to monthly team meetings. The provider had a process for recognising individual staff member's commitment and hard work.

We received mixed feedback from people regarding the food and drink that was available to them. The lunchtime experience upstairs was positive for people. However, downstairs people were not always supported effectively to eat or to enjoy their meal. However, staff demonstrated a good knowledge of people's nutritional needs and their dietary requirements. People received the appropriate health care to meet their needs.

The home had a contract for seven discharge to assess short term placements which were funded by the CCG (Clinical commissioning group). Staff knew the people they cared for well. Staff behaviours and attitude to their work showed they wanted to look after people who were in their care well. However, staff were busy and they did not have as much time as they would like to spend with people. Staff tried to be responsive to people's needs and tried to ensure people’s requests were met in a timely manner but sometimes people had to wait for assistance.

People were treated with kindness by individual staff members and positive interactions took place between the staff and the people who lived at the home. Staff showed concern for people's wellbeing and knew what support provided comfort to people when they became anxious.

People were treated with dignity and staff demonstrated their commitment to continually supporting people to maintain and regain their independence.

Some people were stimulated with activities at certain times of the day during our visit. People did not always have opportunities to maintain links with their local community.

Since our last visit the provider had made further improvements to the environment to ‘brighten up’ and provide more stimulation for people living with dementia. Plans were in place to improve the outdoor garden environment for people. However, it was not clear how people had been consulted on how the area should look.

People were supported to make choices and decisions about their everyday routines. People were encouraged to maintain relationships important to them. People’s family members felt well informed about their relation’s changing needs and felt involved in decisions about their family member’s care and support.

We looked at a selection of care plans which contained people’s life stories. However, some plans contained conflicting information and another did not clearly reflect when a person’s needs had changed.

People and their family members told us they knew how to make a complaint if they wished to do so. They were actively encouraged to put forward their suggestions and views about the service they received and the running of the home. However, they did not always feel confident actions would be taken in response to their feedback.

There was a clear management structure in place at the home. People and their family members had mixed views regarding the leadership of the home. Staff felt supported in their roles and spoke positively about the registered manager. The registered manager had worked hard to improve the culture and encourage team working at the home since our last inspection. However, some staff did not always feel valued by the management team.

We saw good examples of team work and communication between the staff and the registered manager during our visit. The registered manager chose to have a ‘hands on’ approach so they worked alongside the staff team and got to know people who lived at the home well.

There were systems to monitor and review the quality of the service. The management team completed regular checks of different aspects of the service. However, we could not be sure all of the checks were always effective such as, audits of people’s care plans.

Care records we looked at were detailed and gave a good picture of the individual and their individual needs. They were reviewed regularly to ensure they reflected any changes in people's care needs. Staff knew the people living at the home very well and were able to demonstrate how they cared for them and met their individual needs.

We found there was a much more proactive approach in managing mental and physical health care needs. We saw relationships with external healthcare professionals had improved and they were providing regular support when issues were identified.

We looked at a selection of people's daily records such as food charts and turn charts. We found record keeping needed to be more accurate to evidence staff were doing all that was required in care and support plans.

Three inspectors visited Brandon House Nursing Home to follow up on concerns raised during our last visit on 12 August 2013.

We reviewed the care of five people with varying levels of need. Some were unable to communicate with us so we spent a period of time observing how people were being cared for within the home. We also spoke with eight members of staff, the manager and the group's Quality Assurance Manager.

We found the service had made some improvements with pressure care management and the monitoring of people's weights. However, we identified there were still some areas of care and welfare where further improvements needed to be made.

Since our last visit the service had recruited more staff and there was less reliance on agency staff. Staff demonstrated a good understanding of people's needs and people responded positively to them. One staff member told us, "Staff are more content. They are able to support people without being rushed." One person told us, "Staff do a great job. It's a very demanding role and they are very caring.'

Staff told us that new staff were now receiving an induction to the service and spoke positively about the support from the new management team.

People at the home had very complex needs and were unable to tell us about their experiences. We closely observed the care provided to people and looked at associated records. We found there were improvements needed in all five of the standards we reviewed.

Care records were not always accurate and did not demonstrate that people's care and treatment needs were being effectively and safely managed. Action was not taken when it had been identified people had lost significant amounts of weight.

The service had to use a high level of agency staff as they did not have sufficient numbers of staff to cover all the shifts on the rota. We were concerned there were insufficient nursing staff to meet the needs of people at night.

Arrangements to minimise the risk of infection in the home were not always being followed by staff.