Archived: Brookfield Residential Home

Updated 18 February 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 13 November 2014 and was unannounced.

The inspection team consisted of two inspectors.

Prior to this inspection we reviewed information about this service. This included concern in relation to people’s care and welfare from the local authority, Environmental Health Officers and the Medicines Safety and Governance Technician from a Clinical Commissioning Group.

We spoke with two people and one relative during our visit. Other people were unable to share their views and experiences with us because they were frail or unwell, so we gathered information through observation. We obtained views about the care being provided in the service from five health and social care professionals.

We spoke with three care staff and the registered manager. We reviewed a range of records about people’s care and how the service was managed. These included the care records for six people, training records for all staff employed at the home, medication records, accident records and documents given to us by the registered manager that related to how they monitored the quality of the service.

Updated 18 February 2015

This unannounced inspection took place on 13 November 2014. Brookfield Residential Home provides accommodation and personal care for up to eleven people. Two people had been admitted to hospital for care and treatment following serious concerns raised by healthcare professionals about how their needs were being met by the service. The majority of people living at Brookfield Residential Home were living with dementia and had varying levels of dementia related needs, some more advanced.

There was a registered manager in post at the service. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. In this instance the registered manager is also one of the partners in the partnership providing the service and is therefore also the registered provider.

At our last inspection on 5 September 2014 we found the provider was failing to plan and deliver safe and appropriate care to people to meet their needs. We served a Warning Notice on the provider telling them where they were failing and requiring them to address the issues before 28 October 2014. We also asked the provider to make improvements to cleanliness and hygiene in the service, staffing levels and staff training, medication management, how the human rights of people who may lack capacity to take particular decisions are protected and how the quality of the service was monitored.

They sent us an action plan telling us the improvements they were making. During this inspection we looked to see if these improvements had been made. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and that the provider had not responded effectively and promptly to our concerns; very little improvement had been made to ensure people received care that was safe, effective and protected them from harm.

People’s safety was being compromised and they were at serious risk of harm because care was not being assessed and delivered which met their changing needs. There was no system to assess staffing levels and make changes when people’s needs deteriorated, so that staff could care and support people safely. There were insufficient numbers of staff to meet people’s needs at all times, particularly at night. There was poor medicine management and people were not always receiving their medication as prescribed.

Staff did not have the knowledge and skills they need to carry out their role and responsibilities effectively. They did not recognise poor practice which might put people at risk of injury, for example when supporting people to move and transfer. Risks, including nutritional needs were not identified, monitored or managed. People were not supported to have sufficient quantities to eat and drink and maintain a balanced and nutritious diet.

Care was based on routines rather than individual choice, for example the time people went to bed and the time they got up. People’s interests or past hobbies were not explored; they were socially isolated and some were withdrawn. Staff were not provided with guidance on how to deliver the best possible care to people at the end stage of their life in a way that maintained their dignity and comfort.

Care was not personalised but delivered by a task led approach and people’s choices and preferences were not respected. People had not been protected from the risks of receiving care that was unsafe or inappropriate. People had not been referred to healthcare professionals for treatment, support or advice to maintain their health and wellbeing.

Quality assurance systems had not been implemented and the provider was unable to recognise or independently identify where improvements were needed. There was a lack of proactive managerial oversight to ensure that risks to people’s safety and welfare were being identified and managed. The culture of the service was not open and transparent with professionals who were trying to support and the service was not being run in the best interests of the residents.