Bradbury House

Bradbury House provides planned and emergency short term respite care for up to 10 people with a learning disability, some of whom may have additional physical care needs. All accommodation is on the ground floor and in single rooms. There are shared recreational rooms and accessible gardens.

The service was taking steps to apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

There was action being taken to promote choice and control, independence and inclusion to fully reflect the principles and values of Registering the Right Support. Action was being taken to focus support on people having as many opportunities as possible for them to gain new skills and become more independent.

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

There were people who at times expressed frustration and anxiety which placed them, and others at risk of harm. However, risk assessments lacked clear guidance and there were some inconsistencies with approaches from staff. The manager told us about the actions taken to ensure the safety of people and staff. They said staff had attended relevant training and referrals were made for specialist support. This included referrals to specialist nurses to update the strategies.

We responded to concerns about the food made to CQC before and during the inspection. We looked at the stocks of food and found there were adequate quantities of frozen and tinned foods. However, most food was processed and people had limited access to fresh fruit and vegetables. The manager told us they would take action to support staff to prepare fresh meals. Better cleaning routines were required to ensure the fridge was kept clean.

Risk assessments were in place for individual risks. The assessment format had been updated for staff to better detail the identified risk and the measures to minimise the risk.

Safeguarding procedures were on display at the service and staff had attended safeguarding training. The staff we spoke with knew the signs of abuse and felt confident to report their concerns.

While staff said there were staff shortages we saw staffing levels were consistent with the funders allocations of staff hours. We saw there were sufficient staff on duty when people were at the service. Some people were having one to one staff as agreed.

Medicine systems had improved. Staff were to attend training. While there had been medicine errors they were being addressed and systems had improved.

The staff were supported with their roles and responsibilities. The training matrix in place listed the mandatory and specialist training attended. Where training was overdue this was identified. The staff we asked said they had attended all training that was set as mandatory by the provider. Staff had regular one to one supervision sessions.

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. People's capacity was assessed, and best interest decisions reached where they lacked capacity. The manager was reviewing documentation in relation to mental capacity assessments and Deprivation Liberty Safeguards (DoLS). This will ensure a legal framework was in place to make best interest decisions for people identified to lack capacity to make specific decisions.

The staff were knowledgeable about the procedure to follow in the event people became ill during their stay at the home.

The staff were caring towards people. We saw staff use a variety of methods to engage with people. The relative we spoke with said their family member showed signs of enjoyment whenever they went for respite care. Staff told us it was important to develop relationships with people.

The existing support plans were inconsistent. The format was to change to develop more person-centred plans. People’s preferred communication methods were being developed. For example, communication passports and a Makaton board of simple signs were accessible to support people that used this method of communication.

Quality assurance systems were effective and action plans were developed in relation to any required improvements. Audits reflected the findings of the inspection. However, some systems needed to be embedded further to ensure they were effective.

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 last rating for this service was requires improvement (published 12 August 2019) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of regulations.

This service has been rated requires improvement for the second time

Why we inspected

The inspection was prompted in part due to concerns received about allegations of abuse and staffing concerns about the medicines management system. This inspection was carried out to follow up on action we told the provider to take at the last inspection. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will continue to monitor information 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.

Bradbury House provides planned and emergency short term respite care for up to ten people with a learning disability, some of whom may have additional physical care needs. All accommodation is on the ground floor and in single rooms. There are shared recreational rooms and accessible gardens.

The service did not always consistently apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence

The service was bigger than most domestic style properties. It was registered for the support of up to 10 people. The size of the service having a negative impact on people was mitigated by the building design which included wide corridors and level access for people with mobility needs.

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

Risks were not well managed and placed people at potential harm. Risks were not consistently assessed and action plans developed on minimising the identified risk. Where people sustained injuries there were not investigated. This meant staff were not given clear guidance on the measures to reduce the risk.

People were placed at potential risk of harm.

Safeguarding procedures were not followed. This was despite the staff having a good understanding of safeguarding people from abuse and having these procedures on display for reference. Some safeguarding referrals had been made in response to relative’s concerns, but safeguarding referrals were not made for all abuse allegations.

Accidents and incidents were not well managed. This meant trends were not identified and there was little evidence of learning from these events. Organisational policies and procedures such as risk assessments were not always followed. CQC was not notified of all reportable events.

The staff told they “now” felt confident to report poor practice and that their concerns would be taken seriously.

National recognised induction programme was not followed for new staff. . For some staff the induction covered reading care plans and touring the property. The manager has taken steps to ensure the most recently employed staff complete inductions that meet Skills for Care standards. Some staff were assisting with behaviours deemed to be challenging when they had not attended the appropriate training.

The training matrix was not accurate and up to date. The names of staff on the training matrix did not correspond with the names on the staff rota. This meant there was a lack of monitoring on the training staff had attended.

One to one staff supervision meetings with their line manager were not regular although action was taken to address this.

People were not fully supported to have maximum choice and control of their lives. Staff did not support people in the least restrictive way possible and in their best interests.

Mental capacity assessments were in place for some decisions. Where people lacked capacity there were some best interest decisions to impose restrictions through the deprivation of liberty safeguards (DoLS) process. Applications for DoLS were in place for some people that had one to one or two to one support. However, capacity assessments were not in place for all the people that were having this support. This meant steps were not taken to ensure this was the least restrictive action.

People were not able to leave the home independently as there were entry door systems in operation. The staff told us the people using respite care were always accompanied in the community. DoLS were not in place for all the people that had their liberty restricted. Where DoLS applications were in progress they were not reviewed to ensure the restrictions were appropriate.

While staff said the team was "fractured", they said the leadership had improved. The culture and practice was not always consistent with the organisations values of team working, responsibility and leadership. Staff told us there were groups of staff that liked to only work with specific staff. The head of services and managers had taken action to address staffing issues which included changes in shift patterns. The head of care and manager said team building was to be organised.

The registered manager was on a period of absence from the home. An interim manager had been appointed to cover this leave. While the manager had only recently been appointed they had an oversight of the improvements needed.

The recently appointed manager was organising audits to develop an improvement plan. This included areas such as equipment, training, risk assessments and fire safety. The manager told us communication and role modelling were areas being developed. Staff were to be assigned with lead roles, which enabled staff a central point of contact, if they needed advice.

The manager was taking action to ensure staff were following procedures to support improvements and there was to be input from external professionals.

Recruitment processes had been properly followed.

Rating at last inspection

The last rating for this service was Good (published on 17 April 2019).

Why we inspected

We received concerns in relation to the safety of people at risk. As a result, we undertook a focused inspection to review the Key Questions of Safe, Effective and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

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

Follow up

We requested weekly action plans for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Bradbury House provides planned and emergency short term respite care for up to ten people with a learning disability, some of whom may have additional physical care needs. There were four people having short term care.

People’s experience of using this service:

Protocols for medicines to be administered “when requires” (PRN) lacked detail. We recommend the service review and update medicine procedures.

The in-house induction for new staff did not follow Care Certificate standards. This meant the induction for new staff was not comprehensive.

We recommend that the service finds out more about in-house training for new staff which must be based on current best practice.

The home was recently audited by an external company. There were a number of recommendations made in line with the inspection findings. The registered manager said action was being taken. However, an improvement plan was not developed on how the recommendations will be actioned.

The quality of the care plans had improved since the last inspection. Care plans lacked agreed goals although they were clear on people's abilities and how staff were to assist the person in their preferred manner. There was little evidence that where relevant people were supported to maintain and develop their independence.

People were safeguarded from abuse. The staff had attended safeguarding training and knew the procedures to follow where there were concerns of abuse.

Risks were assessed and where they were identified action plans were developed on how to reduce the potential of harm to people.

Staffing levels were good. There were existing vacancies and staffing levels were maintained with relief and existing staff covering vacant shifts.

Systems were in place to support staff with developing their skills and to monitor their performance.

There was a process for referrals for respite care. Staff told us there were visits organised before respite care was offered.

People's capacity was assessed, and best interest decisions taken where people lacked capacity.

Menus were devised and were adapted to the people that were on respite care. Menus in the dining room were in picture format and in words. People's dietary requirements were catered for.

Arrangements were in place in the event people needed medical attention. One person told us the staff were kind. We saw staff supporting people. We saw people enjoyed the attention they received from the staff.

People's feedback was sought about the quality of service delivery. People mostly said the service was good.

Staff told us the team worked well together. They said the registered manager was fair and approachable.

There was learning and partnership working with external agencies

Rating at last inspection:

This service was rated Requires Improvement at the inspection dated 14 March 2018 This report was published on 25 April 2018.

Why we inspected:

This inspection was scheduled and based on previous rating.

Follow up:

We will monitor all intelligence we receive about the service to inform when the next inspection should take place.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on the 14 March 2018 and was unannounced.

This is the first time the service has been rated Requires Improvement.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

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.

Quality Assurance systems were in place to assess and monitor service delivery. Outcomes were assessed and where shortfalls were identified an action plan was devised. Although people's records were securely stored, they were not complete or up-to-date for some people. This was not identified within the audits of outcomes. The views of relatives were gathered about the respite care service.

People told us the types of day to day decisions they were able to make. The staff we spoke with were knowledgeable about the day to day decisions people made. Mental capacity assessments and best interest decision were not complete for all complex decisions. There were inconsistencies with the assessments of capacity for complex decisions and Deprivation of Liberty Safeguards (DoLS) applications.

Steps were taken to ensure medicine systems were safe. People told us staff administered their medicines. Medicine profiles included a photograph of the person and essential information such as known allergies and how the person preferred to take their medicines. Medicine administration records (MAR) charts were signed by staff to indicate the medicines administered. Where “as required” also known as (PRN) medicines were prescribed procedures were not devised on the administration of these medicines.

Risk management systems were mostly effective. Risks were assessed and for some people risk assessments were developed on how to minimise the risks. However, moving and handling risks assessments were devised but lacked detail.

The staff we spoke with were knowledgeable about people’s individual risks and the actions needed to minimise the risks. Individual risks to people included self harm, risk of malnutrition and for mobility impairments. Epilepsy profiles were in place for people at risk of seizures.

There were people who expressed their anxiety and frustration using aggression and self-harm. Staff told us and training records confirmed they had attended positive behaviour management training. Behaviour management plans included the triggers and the actions staff must take to prevent situations from escalating.

Incidents and accidents were reported and were analysed to identify emerging patterns and trends.

The safety of the living environment were regularly checked to support people to stay safe. For example, fire risk assessments, fire safety equipment checks and fire training for staff.

Safeguarding processes in place ensured people at the service were safeguarded from abuse. Members of staff told us and training records showed safeguarding of abuse training was attended. The people we spoke with said they felt safe and the staff gave them a sense of safety.

Staffing rotas were designed to ensure staffing levels were appropriate to meet the needs of people on respite care.

Staff received feedback through regular team meetings where people’s needs, staff’s roles and responsibilities were discussed as well as information shared. The staff were supported to develop the appropriate skills and knowledge needed to meet the needs of people accommodated. The training records provided showed staff had attended training which the provider had set as mandatory. One to one meetings with the registered manager were regular to discuss performance, personal development needs and concerns.

The staff were knowledgeable about the aims of the organization. They knew how these values were embedded into practice. Staff told us the team was stable and they worked well together. They told us the registered manager was approachable.

Care plans were in pictures and words and detailed people’s preferences. They reflected people’s physical, mental, emotional and social needs. People were aware care records were held.

We saw people seeking staff attention and reassurance. Staff knew people’s preferences and how to approach people in a sensitive manner. The relatives we spoke with said their family members showed signs they had enjoyed their respite stay when they returned home.

We made recommendations regarding maintaining records up to date including when required medicines procedures.

As part of this inspection we spoke with two people who use the service, three relatives, the county manager, the team leader, two care staff and a health professional who works with the service. We also reviewed records relating to the management of the home which included, three support plans, daily care records, risk assessments, audits, policies and maintenance logs.

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at.

Is the service safe?

People had been cared for in an environment that was safe, clean and well maintained. The design of the home allowed good access to all areas and security measures provided safety for people using the service.

Support plans gave guidance and instruction to staff on how to meet people's needs in a way which minimised risk for the individual. They ensured that staff had the information necessary to support people safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We spoke with the team leader with regard to the recent Supreme Court ruling and found they were aware of the ruling and had been in contact with the local authority deprivation of liberty safeguards (DoLSs) team. There were no DoLS in place at the time of this inspection.

Is the service effective?

People told us that staff helped them to make decisions and ensured they were happy with what was happening. One person told us 'I can go out by myself, but I like staff with me, they help me find my way.' and 'I am trying to find a job, some staff help me with this'. Staff we spoke with showed good understanding of people's needs, seeking consent and assisting people to make decisions.

We observed staff supporting people in a professional and patient manner. We saw choice being offered and explanations given. We saw staff engaged with people and they responded positively to this interaction by replying or smiling.

Is the service caring?

We saw people laughing and enjoying the company of the staff supporting them. Staff understood how people communicated and how people would express their likes and dislikes during their care and support.

Throughout the inspection we noted people sought advice from staff and had positive interactions with them. We saw people being supported to take part in games and interests as well as routine activities of daily living such as eating and drinking.

Relatives we spoke with commented positively on the support their loved ones received. For example, one relative said: 'they (staff) have learnt mannerisms and behaviours by watching carefully and can deal with difficult situations with '..'

Is the service responsive?

People's needs had been assessed before they used the service. People's needs were reviewed with them and their relatives as appropriate. Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities that were important to them.

We spoke with two people and three relatives of people who use the service. They told us they could talk to staff if they were unhappy about something. They all said they felt confident they would be listened to. People told us they knew how to make a complaint if necessary.

The staff we spoke with were knowledgeable about the complaints procedure and confirmed how they would support people to make a complaint if necessary. One staff member told us: 'if a person has a concern they are encouraged to speak up and they are listened to and action is taken.'

Is the service well-led?

People and their relatives said they were consulted about their views and they completed satisfaction questionnaires. They told us they could approach staff at any time and they felt listened to.

The provider had a quality audit system in place. We saw evidence that when issues had been identified, they were managed appropriately.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others related to the delivery of care.

At our previous inspection in January 2013 we found some people's care records were not helpful because it was not possible to tell if information in people's records was current and accurate. The provider told us how they intended to improve their record keeping so people would not be at risk of unsafe care. At this visit we found records had been improved and were completed and maintained in a consistent way. All documents were signed and dated. Staff we spoke with were confident they and their colleagues were up to date with the content of records.

We looked at how people's medicines were managed. We found there were good systems for ensuring people's medicines were safely looked after. Written plans made sure people received their medicines in ways that met individual needs and preferences. Staff always checked with people's families or GPs if there had been any changes in prescription since their previous stay.

We looked at how the home was kept clean. All the communal rooms and areas, and bedrooms we saw, were very clean. Staff took a pride in this. The manager had systems to keep a check on cleaning being carried out to a high standard.

There was a games room with a pool table and other games and pastimes. People were supported to keep going to their usual day facilities, employment or schools. At weekends they had trips out. We saw the staffing level was varied to suit the support needs and activities of people staying at the home at any time.

Staff were friendly and respectful to people. They had guidance on meeting people's communication needs and we saw they were skilled in communicating with people. One person told us 'I don't like crowds; staff understand that.'

Support plans gave staff detailed guidance about people's care needs, including how to use any equipment. A person staying at the home told us 'I have epilepsy. The staff know what to do when I have a seizure.' However, some records were not helpful because they did not show how old information was or if it came from Bradbury House.

There were safe arrangements for keeping people's money if they wished. Staff were trained in recognising if people might be at risk, and what to do if they had concerns for people's safety.