Archived: Braceborough Hall Retirement Home

Updated 7 October 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. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we 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 team consisted of two inspectors and one assistant inspector.

Service and service type

Braceborough Hall Retirement Home 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 the service 24 hours’ notice of the inspection.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service and six relatives about their experience of the care provided. We spoke with six members of staff including the registered manager, senior care workers, and care workers. Also, we spoke with one visiting health care professional.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection –

We continued to seek clarification from the provider to validate evidence found. We looked at training data and staffing levels.

Updated 7 October 2020

About the service

Braceborough Hall retirement home is a residential care home providing personal and nursing care. 19 people aged 65 and over at the time of the inspection were receiving care. The service can support up to 25 people.

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

The risks to people’s safety were not always assessed, and measures to reduce risks were not implemented. People were not always protected from the risk of abuse as not all staff had received safeguarding training to support their knowledge of safeguarding issues. The investigations into safeguarding issues did not show learning from events. People’s medicines were not always managed effectively. People were not always protected from the risks of infection, as there was a lack of personal protective equipment in some communal areas, and there was a lack of cleaning schedules to show how areas were being cleaned.

People were supported by adequate numbers of staff, however due to staff shortages the registered manager had been required to undertake duties extra to their role. This had impacted on their ability to retain effective oversight of the service. Quality assessment processes were not robust, and this had impacted on the quality of information in people’s care plans to provide staff with clear information on their care. There was a lack of analysis of falls and environmental risks had not been properly assessed.

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; however the policies and systems in the service did not support this practice. The mental capacity assessments in place for people lacked clarity and consistency and were not completed in line with the mental capacity act.

People were supported by staff who were kind and caring. People and relatives told us the staff communicated well with them. Staff told us they felt supported by the registered manager

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 28 April 2019)

Why we inspected

This was a planned inspection based on the previous rating.

We have identified breaches in relation to safe care and treatment, person centred care, recruitment processes, and governance 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 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.