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Archived: Bramble Lodge Care Home Requires improvement

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Reports


Inspection carried out on 25 July 2018

During a routine inspection

This inspection took place on 25 and 31 July 2018. The first day of the inspection was unannounced, which meant that the staff and provider did not know we would be visiting. The second day was announced.

This service provides support and accommodation for up to 41 people who are assessed as requiring residential or nursing care. This includes support for people living with dementia and/or mental health conditions. At time of our inspection there were 19 people living at Bramble Lodge Care Home.

Bramble Lodge Care 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 home is a purpose built, detached building in a residential area of Middlesbrough. It is set out over two floors.

At our last inspection in January 2017 we found that there were continued gaps in records in all areas looked at. Audits had not highlighted any of the concerns which we found during inspection. Staff completed records for people when they had not been involved in their care and care records were not completed in a timely manner. A safeguarding alert for neglect had been upheld in respect of record keeping. We issued a warning notice for this breach of Regulation 17 (HSCA RA) Regulations 2014 in relation to Good governance. We asked the provider to make improvements in this area.

Whilst improvements had been made to quality assurance systems within the service, audits had not identified issues we found with staff training and the fire procedure. We have made a recommendation about provider audits.

We also found at the last inspection that people’s care records did not show if they were subject to a ‘Deprivation of Liberty Safeguard,’ (DoLS). Care plans did not contain any information about people’s capacity to consent or their level of understanding in each of their identified care needs. Staff displayed limited knowledge and understanding of DoLS and best interest decision making had not been carried out when needed. This was a breach of Regulation 11 in relation to the need for consent. We asked the provider to make improvements in this area and this action had been completed.

When we inspected the service, the manager was going through the process of becoming a registered manager having taken up their position in February 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered person’s'. 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.

We found during this inspection that the fire evacuation procedure was not clear. Information provided by staff was inconsistent and contradicted information on notices displayed throughout the building. The manager sent us information following the inspection showing that the fire procedure had been rewritten and that liaison with the fire brigade had taken place. They also provided us with the dates that staff would be trained in the new procedure.

Nursing staff had not always received training or refresher training to develop and maintain their clinical skills in areas such as catheter care. The manager had ensured that care staff were scheduled to have or had received training to be able to carry out their role, including training in areas the provider deemed as mandatory such as health and safety, safe food handling and falls prevention. However, there was no evidence that staff had received face to face people movement training, only an online version. This meant that their competency in this area may not have been thoroughly assessed. The manager sent us a plan following this inspection which set out how the training issues identified would be addressed.

People’s files contain

Inspection carried out on 16 January 2017

During a routine inspection

This inspection took place on 16 January and 3 February 2017. Both days of the inspection were unannounced which meant the registered provider and staff did not know that we would be attending.

We carried out a comprehensive inspection of the service on 09 September, 12 October, 13 October and 22 December 2015 and found that the service was not meeting all of the regulations which we inspected. We identified a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because there were gaps in the information contained in care plans. There was inconsistency between care plans. Regular reviews of risk assessments and care plans had not been carried out. Records relating to the care and support people received each day which included their nutrition and hydration had not been kept up to date.

At inspection in January 2015 we found that the service was not accurately and effectively maintaining records. This meant there was a breach of regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was identified because care plans lacked the detail needed to show that person centred planning was being used to support people in all aspects of their life. People’s involvement in their care was not accurately documented and reviews of care did not evidence how care, support and intervention was reducing and enabling people to live to their full potential.

At this inspection, we identified a continued breach of records. We could see improvements had been made in some areas; however this was not in all of the areas expected. We found gaps in record keeping included topical cream records, dates of opening on topical creams and eye drops and fridge and room temperatures. Repositioning charts had not been fully completed and we found scores on nutritional screening tools were inaccurate. Health and well-being records, which included food and fluid balance information was not completed in a timely manner and were completed by staff who had not been involved in people’s care. There were gaps in care plans and in the frequency of reviews. A safeguarding alert for neglect had been upheld for record keeping. This meant staff had not obtained all of the information they needed when a person started using the service. The registered manager had acted following this and had made changes to pre-admission records to reduce any future risk of harm caused by poor record keeping.

There were gaps in quality assurance processes. Audits had been carried out at the service by the registered manager and registered provider; however they had not highlighted all of the concerns which we had during this inspection.

Some people using the service had been deprived of their liberty to receive care and treatment. This meant people were subject to a 'Deprivation of liberty safeguard,' (DoLS). We could see these applications had been carried out in people's best interests and staff had followed the legal framework of the Mental Capacity Act 2005. However, people's care records did not contain any information to show if they were subject to DoLS, their capacity to consent or their level of understanding in each of their identified care needs. We found that staff displayed limited knowledge and understanding of DoLS and best interest decision making had not been carried in relation to a 'Do not attempt cardio-pulmonary resuscitation' certificate and an influenza vaccination.

Risk assessments were in place for people; however they had not always been reviewed within four weekly intervals as stated on the records. Some risk assessments were inaccurate because they had been calculated incorrectly.

This service provides support and accommodation for up to 41 people who are assessed as requiring residential or nursing care. This includes support for people

Inspection carried out on 9 September 2015

During a routine inspection

This inspection took place on 12 and 13 October 2015 and 22nd December 2015. The first day was unannounced which meant the staff and registered provider did not know we would be visiting. The registered provider knew we would be returning for the second and third day of inspection.

Bramble Lodge can provide accommodation for up to 41 people who need help and support and is situated in a residential area within Middlesbrough. Bramble Lodge is a purpose built building over two floors. There are stairs and a lift to assist people to the first floor. Care and support was provided to people on the ground floor living with a mental health condition and on the first floor for people living with a Dementia. At the time of our inspection there were 35 people living at the home.

At the time of our inspection, the manager had been in post since June 2015 and their application to become a registered manager for the service was in progress. 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.

We previously inspected Bramble Lodge on 22 January 2015. At that inspection we found the service was not meeting all the standards which we inspected. We found that the management of medicines was not always appropriate; some medicines had been unavailable for people who needed them and medicine records had not always been completed. Care plans on the mental health unit did not detail 1:1 sessions with people and monthly evaluations of care plans contained limited information. Care plans lacked evidence of care and support should be provided which also enabled people to live to their full potential.

At the start this inspection we could see that the service had not responded appropriately to breaches in records and medicines as identified in our last inspection in January 2015. On the last day of inspection we could see that the service had implemented new procedures for the management of medicines but further improvements to records were required.

At this inspection we could see that safeguarding alerts had been made when needed. Records had been completed appropriately. All staff knew how to respond to a potential safeguarding alert. Staff knew the procedures to follow if they had any concerns and if they had information they needed to share.

Risk assessments were in place for people and for the day to day running of the service. This meant that the service had acted appropriately to reduce the risks of harm to people, staff and visitors.

There were sufficient staff on duty to provide care and support to people and to ensure the smooth running of the service. People and staff told us that there were enough staff on duty to meet people’s needs safely. We could see that staff had been through a thorough recruitment process which included an interview, reference checks and a disclosure and barring service check.

Appropriate arrangements were in place to manage medicines. Medicine administration records were fully completed and good stocks of medicines were in place for people. Guidance for ‘as and when needed’ medicines was available.

People and staff had access to the equipment they needed. We found that equipment was well-maintained.

We could see that staff had completed a variety of training, such as fire safety, infection control and manual handling. Some training had not been completed by all staff; however we could see that this training had been booked in to be completed in the near future.

Supervision and appraisal was not up to date for all staff; however we could see that planned dates had been put in place. An action plan had been put in place by the service to make sure that the registered provider’s guidelines for staff rece

Inspection carried out on 22 January 2015

During a routine inspection

We inspected Bramble Lodge on 22 January 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

Bramble Lodge is a purpose built care home with nursing, which operates two separate units for different categories of care. One unit is for people with a mental disorder and the other unit is for people with dementia. The service can accommodate a maximum number of 41 people.

The home had a manager who started working at the service in October 2014. The manager was in the process of completing their application to apply to be 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.

People told us they felt safe in the service and we saw there were systems and processes in place to protect people from the risk of harm. Checks of the building and maintenance systems were undertaken to ensure health and safety. However we found that portable appliance testing (PAT) had not been undertaken since July 2013. The manager told us that this had been overlooked and during the inspection arranged this for week commencing 26 January 2015.

We found that people were encouraged and supported to take responsible risks. People were encouraged and enabled to take control of their lives.

We found people were cared for by sufficient numbers of suitably qualified, skilled and experienced staff. Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

We found that improvements were needed to be made in regard to management of medicines. We found that people did not always receive their medicines as prescribed. Medicine records were not fully completed.

Staff told us that they felt well supported and we saw records to confirm that formal supervision had taken place. We saw that most of the mandatory training for staff was up to date. Where there were gaps in training we saw that this training had been planned to take place early in 2015.

There were positive interactions between people and staff. We saw that staff were kind and respectful. Staff were aware of how to respect people’s privacy and dignity. In general we saw that staff were attentive, showed compassion and were courteous. However we did identify that some improvement could be made. We saw that a staff member was providing one to one support for a person who used the service. Another person in the room became upset; however the staff member did not attempt to talk with them when they would have been able to do so without compromising the safety and welfare of the person they were supporting.

The manager and staff we spoke with told us that they had attended training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Some staff we spoke with demonstrated a good understanding of the Act and DoLS; however some staff demonstrated limited knowledge.

People told us they were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People told us that they liked the food provided.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. We found that some care plans contained more detail than others. Some care plans contained a good level of information setting out exactly how each person should be supported to ensure their needs were met. However some care plans needed more development to ensure that they were person centred. Some care plans did not contain any evidence to confirm that they had been developed or reviewed by the person who used the service.

Some risk assessments were better than others. Some risk assessments did not highlight the individual risks to the person or specific action to reduce or prevent the highlighted risk. This meant that actions to keep people safe were not documented and people could come to harm.

We saw that people were involved in activities and outings, however improvements could be made. Activities were limited. This meant that some people were provided with limited stimulus during the day.

Appropriate systems were in place for the management of complaints. People and relatives told us that the manager was approachable. People we spoke with did not raise any complaints or concerns about the service. Staff told us that the service had an open, inclusive and positive culture.

In general there were effective systems in place to monitor and improve the quality of the service provided; however we questioned the effectiveness of the medication audit as this did not identify any of the areas of concern that we identified during the inspection.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we took at the back of the full version of this report.

Inspection carried out on 11 March 2014

During an inspection looking at part of the service

At the inspection in April 2013 we reviewed care records and we found that the care model being used had led to copious care plans being in place and the model did not prompt staff to detail the actions they were taking to support people with the behaviours related to their mental health needs.

At this inspection we found that the manager had worked with staff to ensure all care records accurately reflected people�s needs and the care being delivered. We found that the care records were accurate. The provider has also commenced work looking at the care model being used. The manager showed us the new assessment tools and care plans they had developed. These were seen to be much more informative.

The people we spoke with told us �It is a good home and I like it here�, �I have no problems,� and �I like it here�.

Inspection carried out on 3, 9 January 2014

During an inspection looking at part of the service

We followed up the compliance action set at the inspection in April 2013 around training and found that action had been taken to ensure all the staff had received the required training.

Concerns had been raised around how staff worked with people overnight so we visited early in the morning and spent eight hours at the home. During the visit we spent time observing care practices, talked with six people who used the service, all five night staff, three day staff, two nurses on duty during the day, the deputy manager and manager. We found that staff appropriately supported people and now ensured each person made choices about what they wanted to do. We saw that staff were attentive to people�s needs and treated each person with humanity and empathy.

Staff were aware of the requirements of the Mental Capacity Act 2005 and when appropriate used deprivation of liberty safeguard authorisations. Staff understood the difference between a limitation, restriction and deprivations and appropriately used �best interest� decision-making powers for people who lacked the capacity to make independent choices. Staff had also ensured advocacy provision was available for people who needed support.

People said, �They are good to you here'', ''The staff are very nice�, �They are nice here'' and ''I have no complaints, the staff do a good job.''

Inspection carried out on 2 May 2013

During a routine inspection

We decided to visit the home early in the morning to gain a wider view of the service provided. This was part of an out of normal hours pilot project being undertaken in the North East region. During a routine inspection in November 2012, we found that the home needed to ensure staff took account of issues around consent when people lacked capacity. At this inspection we checked whether the compliance action we set was met.

During the visit we spent time observing care practices, talked with five people who used the service; all five night staff; two day staff; and the temporary manager. We found that staff appropriately supported people and now ensured each person made choices about what they wanted to do. Staff had up dated the care records to show if people had the capacity to make independent choices or if they needed support in this area.

People said ''It is great here'', ''The staff are very nice�, �I do like it here'' and ''I have no complaints it is great here.''

We found that although the staff used the Mental Capacity Act 2005 and Mental Health Act 1983 (amended 2007) further staff training was needed to support staff to apply the legislation to their everyday practice. Also the care records needed to be rationalised and staff needed to provided sufficient detail around how to meet people�s needs.

Inspection carried out on 20 November 2012

During an inspection looking at part of the service

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. In June 2012, we found that the home met seven of the nine outcomes. At this inspection we checked whether the compliance actions we set were met.

At the visit we spent time observing care practices and talked with eight people who used the service as well as the majority of staff who were on duty. Several of the people at the last inspection said that they wanted to go out on their own and felt safe to do but staff prevented them from doing so. We spoke with these people and found that staff practices had changed and they were now able to go out independently.

We found that staff ensured people were appropriately supported and now actively ensured each person made choices about what they wanted to do. People said ''It is better here'', ''I find the staff are very helpful and I do like it here'' and ''I have no complaints it is great here''. One person raised their concerns about a possible staff member�s behaviour, which we shared with the new manager who undertook to investigate the issue.

We found that although the staff understood the Mental Capacity Act 2005 and Mental Health Act 1983 (amended 2007) action was needed to ensure the service adhered to all of the requirements of this legislation.

Inspection carried out on 18 May 2012

During an inspection in response to concerns

The visit took place because the contracts and commissioning team at Middlesbrough Council had shared concerns with us about the recent standards of care delivered at the home. The council had noted that the care practices; handling of medicines; cleanliness and infection control; the building; staff training and quality assurance processes needed to be improved. Therefore, when talking with people and observing practice we widened the scope of the inspection to look at the areas of concerns raised.

We spoke to 14 people during the visit who all felt that the service was fine. Several of these people said that they wanted to go out on their own and felt safe to do so but staff prevented them from doing so. They said that staff had not given them a reason as to why they could not go out.

One person we spoke with was fully aware of changes in their medication. However, staff had not told them the reason why these changes had occurred.

People said ��It is better here but sometimes staff don�t appear to hear what I am saying��, ��I do like it here because the staff try their best to help me��, ''It is excellent here, I have no complaints so that should mean you can finish your inspection now'' and ''I feel trapped here as I can't go out. You know I would always come back and can find my way around, so I can't understand why I can't go out.''

Inspection carried out on 15 February 2010 and 15 February 2011

During a routine inspection

�I have been here 3 years, I like it, its alright. I am about to join in with a game of millionaire now. I can get up and go to bed when I want. Most of the staff are alright. I get myself ready, staff give me my medicines. I can have visitors when I want, my family come at weekends. I go out in the garden with staff. I could say if I had any problems. The food is alright, its good you get a choice of two things�.

�I have been here since October, I had 3 or 4 visits prior to moving in. I get well looked after. Food could be better but its ok, the choice is sometimes limited. I spend most of my time in my room, I do go to the sensory room and watch TV in the main lounge. I know about my care plan and can make decisions. I choose to get up at 8.15. I can have a bath or shower at any time, I am ok I look after myself. I can lock my door. Staff are very genuine, nice warm caring people, I could tell them if I had a problem. Staff help me with my tablets. Only improvement is food�.

�Here 3 years, its alright, clean tidy, food good and good staff. I do what I want, go out independently. Would talk to nurses if any problems, they would help. I have a care plan but I am not bothered about seeing it. I can have a bath or shower whenever I want, no restrictions. I get my medication 3 times a day at the same time. I go to the dining room for my meals. The home provides me with juice which I keep in my room. I can have hot drinks or snacks anytime�.

�My Mum has been here for two years, the home was recommended by her social worker. Home keep us informed, we read care plans and sign our agreement to them. I have visited at mealtimes which included Christmas, I was impressed by the food. In the main the home smells fresh and clean, the lounge has been decorated.

They keep Mum clean and tidy, I am more than happy with what they are doing here�.

Reports under our old system of regulation (including those from before CQC was created)