Little Brook House

Little Brook House is a residential care home providing personal care to up to a maximum of 25 people. The home does not provide nursing care. At the time of our inspection there were 24 people using the service, some of whom were living with dementia.

Little Brook House is a repurposed, 17th Century, grade II listed, former farmhouse which retains many period features. In addition, there are two purpose built, modern wings in which most people are accommodated. There is a communal lounge, separate dining room and 2 conservatories. There is a large, accessible garden.

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

We continued to find improvements were needed to ensure the safe management of medicines. Some risks to people had not always been assessed and planned for. The systems and processes to safeguard people from the risk of abuse or avoidable harm needed to be more robust. The systems in place to report, investigate and learn from incidents affecting people’s safety were not fully effective. Planned staffing levels were not always being achieved but this had not impacted on people’s needs being met.

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. Improvements had been made to ensure that the Mental Capacity Act 2005 was fully understood and implemented in line with legal frameworks. Completion rates for training improved, but the supervision programme needed to be further embedded. People received appropriate support with eating and drinking. Improvements were underway to ensure all areas of the home were safe, clean and well maintained. Overall, staff worked closely with a range of community healthcare professionals to meet people’s healthcare needs.

Governance processes were in place but needed to be more effective. People received person centred care but records did not provide assurances that they were consistently being supported to participate in regular social and leisure activities. The leadership team and staff worked with a range of health and social care professionals to meet people’s needs and to drive improvements within the service.

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 requires improvement (published 1 December 2022).

Why we inspected

This inspection was prompted by a review of the information we held about this service, to review the rating, and to follow up on breached of the legal requirements found when we last inspected.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance the service can respond to COVID-19 and other infection outbreaks effectively.

We conducted an unannounced focused inspection of this service on 25 October 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, arrangements for consent, good governance at this inspection.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and Well led which contain those requirements.

The overall rating for the service remains requires improvement.

We have found evidence the provider needs to make improvements. Please see the safe, effective and well led key question sections of this full report.

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

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

Enforcement

We have identified breaches in relation to risk and medicines management, the effectiveness of the safeguarding systems in place, governance, and the recruitment of staff.

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 to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Little Brook House is a residential care home providing personal care to up to a maximum of 25 people. The home does not provide nursing care. At the time of our inspection there were 24 people using the service, some of whom were living with dementia.

Little Brook House is a repurposed, 17th Century, grade II listed, former farmhouse which retains many period features. There is a communal lounge, separate dining room and 2 conservatories. There is a large, accessible, garden.

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

Whilst we found no evidence that people had been harmed, risk to people had not always been assessed and risk management plans were not always in place to guide staff Improvements were needed to always ensure the safe and proper use of medicines . Sufficient numbers of suitably skilled staff were not always deployed. Some areas of the home needed to be more effectively cleaned. Staff understood their responsibility to report safety related incidents and a fuller, monthly, analysis of incidents and accidents had been introduced. Staff demonstrated a commitment to keep people safe from harm.

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, improvements were needed to ensure that the Mental Capacity Act 2005 was fully understood and implemented in line with legal frameworks. Completion rates for training were variable and supervision was not always taking place. Staff did not always have time to provide support to eat and drink in a person centred and unrushed manner. There were areas of the home which did not provide fully accessible spaces for people to use safely and independently. The provider, who had taken on ownership of the service in February 2022, was taking action to address this. There was evidence that staff worked closely with a range of community healthcare professionals, although some concerns were raised about whether people always experienced positive health outcomes.

There had been a number of leaderships changes within the service over the last 12 months and this had impacted on staff morale, on the continuity of support they received from managers and on the effectiveness of the governance arrangements in place. Relatives were confident that staff cared for people with kindness and compassion and promoted their family members individuality. Meetings were held where family and friends were able to share their views and discuss issues with the leadership team.

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 10 September 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement with breaches based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led key question sections of this full report.

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

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

Enforcement

We are mindful of the impact of the 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 breaches in relation to risk management, governance, consent and staffing.

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.

We found the following examples of good practice;

The registered manager had created a separate entrance for staff, people who lived at the home and visitors. The new visitor entrance led into the relative's visiting room which enabled them to be screened, sanitise their hands and meet their family members, maintaining social distancing, and without the need to access the main building. Visits were arranged in advance through a booking system and times were staggered to minimise the number of visitors at any one time.

Staff provided compassionate care to people when they were isolating, keeping them entertained and reassured. Socially distanced entertainers were employed to perform in the garden which we observed was very well received.

The home had a designated infection prevention and control lead who ensured risk assessments were completed for staff at risk. Staff were supported to shield or were offered the opportunity to move to non contact duties.

The registered manager was very open and transparent, keeping relatives informed of what was going on in the service in real time email communications, which included any changes to visiting and the outcome of their recent IPC audit.

Little Brook House is a care home that provides accommodation and personal care for up to 20 older people.

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

At our last inspection we identified governance systems were not consistently effective in driving development. At this inspection we found improvements had been made. Quality assurance systems were effectively in place and helped to ensure the quality and safety of care was routinely monitored, assessed and improved upon accordingly.

Staffing levels were based on individual support needs of the people who were living at the home.

Safe recruitment procedures were in place. People received safe and effective care from staff who had been appropriately recruited and had undergone the correct recruitment checks.

Staff received regular supervisions and appraisals. Staff were also supported with a variety of different training, learning and development opportunities to support their skills and abilities.

Medication processes and procedures were safely in place. Staff were appropriately trained, and care records contained the relevant information in relation to medicine support people needed. We identified several administrative errors which the registered manager responded to and immediately rectified.

People’s support needs and areas of risk management were assessed and determined from the outset. Support needs and areas of risk were regularly reviewed, and staff were provided with the most relevant and up to date information they needed.

People were protected from avoidable harm; safeguarding and whistleblowing procedures were in place and staff knew how to report any concerns they had as a way of keeping people safe.

People were supported to have maximum choice and control of their lives and staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

It was evident during the inspection that the staff team were familiar with the people who lived at Little Brook House. We discussed with the registered manager how more detailed, person-centred care information would be beneficial.

Activities and stimulation were primarily offered on a one to one basis. Staff provided activity support that was tailored around individual choice and preference.

There was an up to date complaints policy in place. Complaints were responded to and managed in line with company policy.

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’ (report was published on 18 March 2017)

Why we inspected

This was a planned inspection based on the previous rating.

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.

The inspection was unannounced and was carried out on 13 and 19 January 2017.

At our previous inspection in July 2015 we identified the provider was not meeting a number of regulations. These related to safeguarding people from abuse; risk assessment; person centred care; staffing levels; staff training and supervision and recruitment; safe management of medicines; and good governance, including record keeping and monitoring and assessing the quality of care and health and safety and the environment. We issued enforcement notices in relation to person centred care; safeguarding adults from abuse; good governance and staffing levels. Following the inspection, the provider sent us an action plan telling us the steps they were taking to make the improvements required.

We inspected again in January 2016 to check they had met the requirements of the enforcement notices and found they had made the required improvements. However, we identified some on-going issues with regards to the provision of person centred care and staff training and supervision. We judged that the provider remained in breach of these two regulations.

At this inspection we found significant improvements had been made.

There was a registered manager in place at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

The registered manager had identified and implemented a number of service audits and monitoring systems. Whilst improvements had been made as a result of these, there was still some work to do to fully embed these new systems for monitoring and assessing the quality and safety within the home. Incidents and accidents were recorded and actions taken, although there were some missed opportunities to learn lessons from these.

People and relatives told us they felt the home was safe. Staff had received safeguarding training, demonstrated an understanding of key types of abuse and explained the action they would take if they identified any concerns.

Individual and environmental risks relating to people’s health and welfare had been identified and assessed to reduce those risks.

Systems were in place for the storage and administration of medicines, including controlled drugs. Staff were trained and their competency assessed to administer medicines.

Staff followed legislation designed to protect people’s rights and ensure decisions were made in their best interests. The registered manager understood Deprivation of Liberty Safeguards and had submitted requests for authorisation when required.

There were sufficient staff deployed to meet people’s care, emotional and social support needs. Activities staff were employed to engage people in planned activities throughout each week.

Staff treated people with dignity and respect and ensured their privacy was maintained. Staff were kind and caring, had time for people and sat and listened to them when they wanted to talk.

People were supported to maintain their health and well-being and had access to healthcare services when they needed them.

Initial assessments were carried out before people moved into Little Brook House to ensure their needs could be met. Information was used to develop plans of care for people. A new electronic care planning system was in the process of being implemented.

The service was responsive to people’s needs and staff listened to what people said. People and, when appropriate, their families or other representatives were involved in decisions about their care planning.

People were supported by staff who had received an induction into the home and appropriate training, professional development, supervision and appraisal to enable them to meet people’s individual needs. Staff meetings took place and staff said these were helpful and enabled issues to be discussed. Staff felt supported by the management team and were confident to raise any issues or concerns with them.

People were supported to have enough to eat and drink and their specific dietary needs were met.

People and relatives were encouraged to give their views about the service. People and relatives confirmed they knew how to make a complaint and would do so if they had cause to.

Plans were in place to manage emergencies including alternative accommodation should the home need to be evacuated. The environment and equipment was regularly checked and servicing contracts were in place, for example for the hoists and stair lift.

Little Brook House is a privately run residential home for up to 25 older people, some of whom are living with dementia. The home also provides a respite service. There were 18 people living at the home at the time of our inspection.

The home had a new registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 unannounced inspection on 26 June 2014, the provider was in breach of six regulations relating to; Respecting and involving people who used the service; Care and welfare; Safeguarding people from abuse; Safety and suitability of premises; Staffing; and Assessing and monitoring the quality of the service. The provider sent us an action plan telling us what they would do to meet the requirements.

We carried out a further unannounced comprehensive inspection on 30 & 31 July and 3 & 19 August 2015 under the new Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and found some improvements had been made. However, the provider remained in breach of six regulations relating to; Care and welfare of people; Safeguarding people from abuse; Safe care and treatment; Staffing; Fit and proper persons employed; and Good governance.

We took action and issued enforcement notices against the provider in relation to Care and welfare of people; Safeguarding adults from abuse; Staffing and Good Governance due to the on-going breach of these regulations. We told the provider they must meet the requirements of these regulations by 14 December 2015. The provider sent us an action plan to tell how they would do this and to tell us how they would make improvements to meet the other regulations.

We undertook an unannounced focused inspection on 21 January 2016 to check they had followed their plan and to confirm that they now met legal requirements in relation to the enforcement notices. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Little Brook House on our website at www.cqc.org.uk. We did not inspect the other breaches of regulation at this inspection and will do so when we return to carry out our next comprehensive inspection.

Staff had received training in how to safeguard adults from abuse. They understood how to recognise the signs of abuse and report any concerns within the home or to CQC. We judged that the provider had fully the met the requirements of this enforcement notice.

There were sufficient staff deployed to meet people’s care needs. We observed staff responding promptly to people’s requests for support. Staff told us there were enough staff most of the time, although there were still times when they were stretched. People told us there were enough staff to meet people’s personal care and support needs although some people we spoke with said staff did not have time to sit and chat with them. The registered manager told us they were recruiting additional staff and would be increasing staffing on each shift.

Staff had completed additional training in some key areas. However, there were outstanding training requirements for several staff. The registered manager had a training schedule in place for the next twelve months, although we told them that this needed to be completed more urgently due to the length of time training had been outstanding. We judged the provider had met the requirements of the enforcement notice. However, there was still further work to be done.

Care plans and other records had improved. The registered manager was in the process of transferring care plans over to a new format and this was a work in progress. However, some people’s care plans were not always sufficiently up to date to provide staff with the information they needed. Staff were aware of people’s individual care needs and risk assessments and knew how to mitigate the risks, although this was not always recorded effectively. People whose care we tracked had received appropriate healthcare interventions when required. We judged the provider had met the requirements of the enforcement notice although there was still work to be completed.

People’s care records were now stored securely and confidentially, although some people’s records were not always accurate and fit for purpose. New quality assurance systems had been put in place to assess and monitor the quality of the service. However these were not yet fully effective.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take in the main report.

At the time of our visit 20 people were accommodated at the home. We spoke with eight people who lived at the home during our inspection in order to hear about their experiences of living at the home.

We spoke with three care staff and the home's manager in order to hear what they had to say about how the home functioned.

We contacted two local GP surgeries to obtain their opinions about the care their patients received at the home.

We gathered evidence against the outcomes we inspected to help answer our five key questions.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found.

If you want to see the evidence supporting our summary please read our full report.

Is the service caring?

People told us the home's staff were polite, helpful, willing and cheerful. They said their choices and preferences were respected and told us they were involved in decisions about the care and support they received.

People's privacy and dignity was not always respected.

Is the service responsive?

A local General Practitioner (GP) with patients who lived at the home, told us they thought the following about Little Brook House. 'The home is well run with caring staff. Carers are generally helpful and well informed. Management of patients is satisfactory. Requests for visits are appropriate. Patients like the ambience of the home and the catering is exceptional'.

Nationally recognised assessment tools were not used to identify the potential risk of harm to people from matters such as pressure sores, falls and malnourishment.

People's needs had not always been comprehensively assessed or the support they required planned in a way that reflected relevant guidance and ensured their safety and welfare.

Is the service safe?

People could be sure they were cared for, or supported by, suitably qualified, skilled and experienced staff.

People who used the service, staff and visitors were not properly or fully protected against the risks of unsafe or unsuitable premises.

The registered person had not responded appropriately to allegations of abuse.

Our review of records showed people were not protected from the risks of unsafe or inappropriate care and treatment because their records did contain all the proper information about the support they needed.

Is the service effective?

Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare and avoid unlawful discrimination.

Is the service well led?

The provider had arrangements in place to check and monitor the quality of the service people received however systems to manage risks to the health, safety and welfare of people using the service were not sufficiently robust.

One person told us "I couldn't have come to a better place, I am very happy here." Another person said "The food is great and the garden is truly beautiful." A relative told us "I feel assured that mum is receiving the best care available. Nothing is too much trouble for the staff."

We found people were involved in writing and reviewing their care plans and had signed them when they were amended. Their needs were assessed and these needs were identified in the care plans. Staff told us they followed the care plans and we saw this where a person was given their medication.

Medicines were administered safely and when people required them. Appropriate systems were in place to order and store medicines. The staff maintained appropriate records of administration.

We looked at staffing and found staff were suitably skilled and qualified for the roles they carried out. There were sufficient numbers of staff on duty and the manager told us they worked on the floor when extra support was required.

We found the service had an effective complaints system in place and complaints were listened to in good time. The service responded to complaints and worked with the complainant to reach a favourable solution to them.