Bryn Haven

Updated 13 November 2020

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. This was a targeted inspection to check on specific concerns we had about falls.

As part of this inspection we also looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by three inspectors. Two inspectors visited the service on the first day of the inspection. One inspector spoke by telephone with the general manager on the second day of the inspection.

Service and service type

Bryn haven is a ‘care home’. People in care homes receive accommodation and nursing or 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.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave a short period of notice of the inspection so that we could have some preliminary discussions around the use of Personal Protective Equipment (PPE) on inspection. The inspection took place on 8 October 2020 with a site visit, we continued on 9 October with a follow up telephone call to the general manager.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and asked Healthwatch Stockport for their views on the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.

During the inspection

We spoke with the general manager, an area manager, the training manager and the nominated individual for Borough Care Limited. The nominated individual is the person appointed to represent Borough Care Ltd in it’s dealings with CQC.

We reviewed a range of records relating to the concerns raised and the management of the service. These included risk assessments, care plans, daily records and incident/ accident forms.

After the inspection

We continued to seek clarification from the management team to validate evidence found. We looked at training data and records relating to monitoring, auditing and quality assurance.

Updated 13 November 2020

This inspection was carried out over two days on the 6 and 15 March. Our visit on the 6 March unannounced. At the last inspection on 25 and 26 January 2016 we rated the service as requires improvement overall. We identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014, which related to risk assessments, infection control, medications, Notification of authorised DoLS applications, the need for consent, ongoing supervision and appraisals for staff and effective governance systems.

This inspection was to check satisfactory improvements had been made and to review the ratings. The provider sent us an action plan that detailed how they would make improvements to become compliant with the regulations. At this inspection we found improvements to the service and no further breaches to the regulations.

Bryn Haven is a residential care home located on the outskirts of a large housing estate in Brinnington, Stockport. It is located near local facilities, a main road and a bus route that provide direct access into Stockport town centre. The home is one of a group of eleven homes managed by a 'not for profit' organisation; Borough Care Limited. Bryn Haven is registered to provide personal care and accommodation for up to 42 older people

A registered manager was in place. 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.

People living at the service, told us they felt comfortable and happy living at the service. The atmosphere was relaxed and welcoming with lots of information available to people about the service.

We saw the food was attractively presented with good size portions. People told us they enjoyed the meals. The dining areas were relaxing and well maintained and enhanced the dining experience.

Activities were provided by the Activities and Lifestyle Facilitator (ALF) and visiting entertainers. The service provided games and activities to help provide access to regular events throughout the week. We saw that meaningful activities were provided by a full time activity co coordinator based on people's personal preferences. They have a dementia group that they attend in the community and participate in the arranged outings.

There was a long-standing staff team in place, with low levels of turnover. This meant that staff knew the people they provided care and support to very well. Staffing levels had been recently revised by the registered provider to provide senior staff and deputies on duty each day. This initiative provided access for everyone to senior leadership and consistent management of the service over a seven day period.

We recommended the registered provider reviews published guidance to help them to demonstrate how staffing levels are calculated to meet people’s needs. Staff were recruited following a safe and robust process to make sure they were suitable to work with vulnerable people.

Procedures were in place to minimise the risk of harm to people using the service. People received their medicines safely and as prescribed by their doctor. The service had regular auditing of medications to make sure they were being appropriately managed at all times.

Staff understood how to recognise and report abuse which helped make sure people were protected by well trained and informed staff.

Risk screening tools had been developed to reflect any identified risks and these were recorded in people’s support plans. The risk screening tools gave staff clear instructions about what action to take in order to minimise risks e.g. for falls.

Staff understood the need to obtain verbal consent from people using the service before a care task was undertaken. Staff were seen to obtain consent prior to providing care or support. Support plans had been developed to incorporate individual information relevant to each person.

The building was very clean and well maintained and developed to meet the different needs of people living there. The service had lots of areas designed for people who had dementia and enabled them to enjoy the facilities on offer.

Staff had access to personal protective equipment (PPE) to help reduce the risk of cross infection for example disposal gloves and aprons.

The environment had been adapted in many areas to create a bright looking building with lots of pictures and signs of interest which generated conversations with everyone in the service and helped orientated people to where they were.

Staff received regular training and support to ensure they had the necessary skills and updates to meet people’s needs. Staff told us they were receiving regular supervision sessions and appraisal. This meant that staff were being appropriately supported to fulfil their job role.

We saw there was a complaint and compliments policy accessible to each person living at the service. The people living at Bryn Haven and visiting relatives we spoke with told us they had no concerns or complaints. The service had developed a ‘Complements tree’ at reception. This was an innovative idea to encourage anyone to leave a comment to hang on the tree to offer their feedback if they chose to.

The registered manager and registered provider had thorough systems in place to monitor the quality of the service. The registered manager was innovative in her vision to improve and develop the service with lots of ideas they were hoping to start in the year.