Archived: Brecklands Nursing Home

Updated 11 April 2016

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 06 January 2016 and was unannounced.

The inspection team comprised one inspector and a specialist advisor. A specialist advisor is someone who has current and up to date practice in a specific area. The specialist advisor who supported this inspection was a registered nurse.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. We reviewed information we held about the service, including previous inspection reports and notifications of significant events the provider sent to us. A notification is information about important events which the provider is required to tell the Care Quality Commission about by law. We used all this information to decide which areas to focus on during the inspection.

We spoke with five people who used the service and two of their relatives. We spoke with one visiting healthcare professional who was a community nurse.

We looked at six people’s care and support plans. We reviewed other records relating to the support people received and how the service was managed. This included some of the provider’s checks of the quality and safety of people’s care and support, staff training, recruitment records and staffing rotas.

We spoke with the management team, including the provider, administrator, clinical lead, a nurse, two care staff and the cook.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

The service was last inspected on 25 November 2014 when no concerns were identified.

Updated 11 April 2016

The inspection took place on 06 January 2016 and was unannounced.

Brecklands nursing home provides accommodation for up to 19 people who require nursing and personal care. At the time of our inspection there were 16 people living at the service.

The provider is registered as an individual and as such does not require a registered manager. A registered provider is a person who has registered with the Care Quality Commission to manage the service. The registered provider are also '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. The provider was present during our visit and also had a clinical lead in post.

Systems were in place to identify risks and protect people from harm. However these were not consistently followed, leaving people at risk and with delayed treatment. We found that staff did not consistently follow a care plan and risk assessment in two incidences relating to pressure areas. The maintenance of the environment was in need of attention and there were areas which were cluttered and unsafe. We observed that fire doors were wedged open, which presented a risk to people living at the service and others in the event of a fire.

The service is purpose built and accommodation is provided over two floors in single occupancy rooms. A passenger lift provides access between the floors. There were handrails along corridors to help people move around the building safely. There are two communal lounges, a conservatory and a dining room. The service had a cat which people told us they enjoyed seeing and a bird which was kept on the first floor.

People were protected against the risk of abuse as the provider took appropriate steps to recruit suitable staff, and staff knew how to protect people from harm.

People were supported to access healthcare from a range of professionals inside and outside the service and received support with their nutritional needs. This assisted them to maintain their health.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely.

There were sufficient numbers of staff on duty to keep people safe and to meet people’s needs. Staff recruitment procedures ensured only those staff suitable to work in a care setting was employed.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Staff were trained in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). Decisions were made in people's best interests where they could not make decisions for themselves.

Staff treated people with kindness, respect and dignity, and supported people to maintain their privacy and independence. People made choices about who visited them at the service. This helped people maintain personal relationships with people that were important to them.

People knew how to make a complaint if they needed to. Complaints received were fully investigated and analysed so that the provider could learn from them.

People, who used the service, and their relatives, were given the opportunity to share their views about how the service was run through meetings and feedback surveys.

Quality assurance procedures identified where the service needed to make improvements and where issues had been identified the provider took action to continuously improve the service.

People were encouraged to maintain their interests and hobbies and staff supported their personal preferences. People's care records were kept up to date to reflect the care and support they received each day from staff.

People were protected from nutrition and hydration associated risks with balanced diets that also met their likes and dislikes.

Staff were supported by the provider, clinical lead who was a registered nurse and other registered nurses through regular team meetings and observation. Staff had regular supervision sessions and felt their training and induction supported them to meet the needs of people they cared for.

People and their relatives felt the staff had the skills and knowledge to support people well.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.