Archived: Bournbrook Manor Home Ltd

Bournbrook Manor Home Ltd is a residential care home providing personal care to 19 younger and older people at the time of the inspection. The service can support up to 23 people.

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

During the last inspection concerns were identified with the management of the home. During this inspection we found similar and additional concerns. The management team did not have the skills, knowledge and experience to ensure people’s needs were identified and assessed.

People’s known risks were not identified, assessed and mitigated, this included risks associated with choking. There was insufficient guidance for staff to follow if a person were to have a seizure. The provider’s systems and processes to ensure known risks to people were assessed and mitigated were inadequate. This placed people at immediate risk of harm. Despite our findings people told us they felt safe.

Fire safety measures were not adequate to keep people safe. The provider’s systems and processes to assess and mitigate fire risks had failed. We were not assured infection prevention control measures were safe and protected people from the risks associated with COVID-19. The provider’s systems had not identified the government guidance around COVID-19 was not being followed.

It is a legal requirement for the provider to display the home’s Care Quality Commission (CQC) rating on their website and in the home, the provider had failed to do this. The provider failed to comply with conditions on their registration, this included not having a manager registered with CQC.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe and well-led the service was not able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture. Care plans were not person-centred to promote people’s dignity. The ethos, values, attitudes and behaviours of leaders could not enable staff to ensure people using services lead inclusive and empowered lives. We asked the provider to review everyone’s care plans to ensure people’s needs and areas of risks were identified, and sufficient planning and risk mitigation was in place.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 March 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found there were not sufficient improvements made and the provider was still in breach of regulations. This service had been rated requires improvement for the last three consecutive inspections, with this rating being inadequate.

Why we inspected

We received concerns in relation to risk management, an incident where a person had choked and infection control. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. You can see what immediate 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 Bournbrook Manor Home Ltd on our website at www.cqc.org.uk.

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.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, governance, failure to have suitably skilled and qualified people employed, failure to comply with conditions of registration and failure to display ratings at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Bournbrook Manor Home is a residential care home that provides accommodation and personal care and support to a maximum of 23 older people and for some older people living with dementia. At the time of our inspection 18 people were living at the service.

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

People told us they felt safe. Some care plans did not describe measures for staff to reduce risks as much as possible or contain relevant information to keep people safe.

Personal Emergency Evacuation Plans (PEEPs) did not give staff members detailed instructions to follow for each resident in the event of a fire or emergency.

Staff had regular safeguarding training and knew about the different types of abuse. Where lessons could be learned to improve the service and make the care people received safer; these were not always identified and addressed.

People were not consistently supported to be involved in the planning or reviewing of the care they received.

The provider’s quality audit system for the environment was not effective. Systems in place to demonstrate how the service monitored accidents, incidents or safeguarding concerns were inconsistent.

The provider was not consistently notifying us about incidents that occurred within the home.

The provider’s systems had not been effective at improving the quality of the service and the service had failed to achieve and sustain a minimum overall rating of 'Good' at three consecutive inspections.

People told us they felt well cared for by staff who treated them with respect and dignity and encouraged them to maintain relationships and keep their independence for as long as possible.

Staff spoke positively about working for the provider. They felt well supported and that they could talk to the management team at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.

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 04 April 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about the management of safeguarding incidents. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well Led sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bournbrook Care Home 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to statutory notifications and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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.

Bournbrook Manor Home is a residential care home that provides accommodation and personal care and support to a maximum of 23 older people and for some older people living with dementia. At the time of our inspection 15 people were living at the service.

People’s experience of using this service:

¿ People told us they felt safe. Safeguarding systems and practices protected people from abuse.

¿ However, people were not always kept safe because risks were not always assessed, monitored or mitigated.

¿ People shared mixed feedback in relation to staffing levels. However, staff told us there were enough staff available to meet people’s needs.

¿ Systems and practices required improving in relation to the safe management of medicines.

¿ Accidents and incidents were not always followed through with the appropriate action to minimise the risk of re-occurrence. Where lessons could be learned to improve the service, and make the care people received safer; these were not always identified and addressed.

¿ People received care from staff who had not always completed mandatory training the provider had required.

¿ Staff involved and consulted a range of health and social care professionals to ensure people's healthcare needs were met.

¿ People told us they enjoyed their meals but were not enabled or involved in the planning of their meals.

¿ Although staff knowledge of Mental Capacity Act (2005) had improved people did not always have their legal rights protected as the staff did not know which people had Deprivation of Liberty Safeguards authorisations in place or how to support people in the least restrictive way.

¿ People said staff were kind and caring but interactions between staff and people were generally task orientated with limited sustained interaction.

¿ People’s dignity, privacy and confidentiality were compromised on occasions

¿ There were limited opportunities for engagement and stimulation for people living with dementia.

¿ People did not always receive care and treatment that was responsive to their needs or provided in a person-centred way. People's care plans were not consistently being followed and some were not current or reflective of people’s needs.

¿ People were not consistently supported to be involved in the planning or reviewing of the care they received.

¿ Relevant care documents were not accessible to meet people’s individual communication needs.

¿ People told us they felt confident to raise a complaint. However, Information about how to raise concerns had not been produced in an accessible format for people who had a visual or cognitive impairment.

¿The provider had developed systems for identifying, assessing and mitigating risks, however, these had not always been operated effectively. The registered manager carried out audits of the service but these had failed to ensure that people were always safe and that their needs were being met.

¿ The providers systems had not been effective at improving the quality of the service and the service had failed to achieve and sustain a minimum overall rating of ‘Good’ at three consecutive inspections.

¿ A new management team had been introduced and they were very committed to driving improvement to enhance the quality of the care and support delivered to people.

Rating at last inspection:

The service was rated Requires Improvement overall. Our last report was published on 02 May 2017.

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received. At this inspection on 05 March 2019, we found the provider had failed to sustain and build on improvements and the service had deteriorated.

Enforcement:

We found that the provider was not meeting all of the requirements of the law. We found multiple breaches in regulations. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

At our last comprehensive inspection in April 2016 we found that the registered provider was in breach of regulations. This was because the provider did not have effective systems in place to assess and monitor risks relating to the health, safety and welfare of people using the service. The provider did not have robust systems in place to monitor the quality of the service. In addition the provider did not ensure that the care and treatment of service users was provided with the consent of the relevant person. Following the inspection the registered provider submitted an action plan detailing how they would improve to ensure they met the needs of the people they were supporting and the legal requirements.

We undertook this unannounced inspection on the 2 May 2017 to check that the registered provider had followed their own plans to meet the breaches of regulations and legal requirements.

We found that the registered provider had addressed some of the concerns that we had identified at our last inspection and had met their action plan and the breaches of regulation. We found that the provider had further improvements to make in respect of enhancing the knowledge of the Mental Capacity Act (MCA) within the staff team and to improve auditing processes.

The registered manager was present during our inspection. 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 that could tell us said that they felt safe living at the home. People were supported by staff who had received training on how to protect people from abuse. There were enough staff on duty to meet people’s needs and recruitment checks on new staff had been completed before they started to work. People received their medicines as prescribed.

People’s consent was sought, but staff had limited knowledge of the MCA and the Deprivation of Liberty Safeguards (Dols). Staff told us they had the knowledge and skills to support people to meet their individual needs. People’s nutritional and dietary needs were assessed and people were supported to eat and drink sufficient amounts to maintain their health. People were supported to access a number of healthcare services.

Staff demonstrated some caring and compassionate practice and staff demonstrated a positive regard for the people they supported. People received care and support from staff who knew and understood their individual preferences and needs. People’s privacy and dignity was respected.

People’s needs had been assessed and most care plans developed to inform staff how to support people appropriately. Activities were provided but improvements were planned to ensure people had the opportunity to participate in activities of interest to them. People felt able to complain and were confident concerns raised would be addressed.

People had confidence that the registered manager was improving the service they received. People and staff consistently told us that the registered manager was approachable. We found that although there were some systems in place to monitor and improve the quality of the service provided, these were not always effective in ensuring the home was consistently well-led.

The registered manager was present during our inspection. 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 that they felt safe living at the home. Relatives confirmed that they thought the home kept people safe. Staff were able to demonstrate a good understanding of procedures to follow to keep people protected from abuse and harm. We found that the registered providers systems and processes had not always ensured the risk to people was minimised. Although there had been no medication errors in the last twelve months, systems were not robust enough to ensure that medications were safely administered.

Staff we spoke with told us training was provided, however training to develop staff’s knowledge in relation to specific health conditions was not provided. Care plans did not reflect people’s level of capacity. Staff lacked the understanding of the Mental Capacity Act (2005) and what it meant for people living in the home. People’s rights had not been supported in line with the legislation.

The home did not always have effective systems to monitor and improve the quality and safety of the care provided to people. People, their relatives and staff consistently told us that the registered manager was kind and approachable. People’s views had been sought but not consistently acted upon.

You can see what action we told the provider to take at the back of the full version of this report.

People were supported to have food and drink in sufficient quantities to meet their needs and help maintain good health. People’s health was supported by access to appropriate health professionals.

We saw interactions between staff and people living at the home which were kind and compassionate. People gave us mixed feedback about the staff. Some people said staff were kind and did all they could to help them, others told us some staff were not caring.

People were enabled and encouraged to make decisions about their care. People told us that they had been involved in planning and agreeing to the care provided. People and those that mattered to them did not always contribute to the reviewing of care plans. Staff knew people well and could describe individual preferences of the people they were supporting.

We saw that some arrangements had been made to provide people with interesting things to do. However activities were not always person centred to meet people’s individual choices.

There was a complaints process that people and their relatives knew about. People told us that they felt comfortable to raise concerns and told us staff would listen and support them. Systems were not in place to record complaints and concerns that would help the provider to learn and to improve the home.

At this inspection we spoke with five people who lived in the home. All of them confirmed that the staff were caring, they were given choices about how they were supported and that they felt safe. Included in their comments were: "I can tell staff how I want things doing and they ask me if they are doing it right," "The staff are little angels, they treat me with respect," and "The manager (and deputy manager) controls the staff properly."

We saw that staff treated people with respect and responded when people asked for assistance. People were not overly restricted by routines or regimes within the home; for example they could choose where to spend time in their room or in the communal areas, and exercised choice about when, where and what to eat.

Staff at the home were knowledgeable about people's health conditions and the care and support people needed. People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Staff spoken with were able to tell us about people's needs so that they received care in a way that they preferred. The relatives spoken with told us they were consulted about their relative's care and kept informed about their health so they felt involved in their care. One of the relatives told us 'I know that my relative is truly loved by the staff here, they let her be who she is and has always been."

People received there medication as it was prescribed.

There were enough care staff to ensure that people had the care and support they needed. Care staff were knowledgeable about people's care needs.

There were systems in place to monitor how the service was provided. Records needed to be improved so that important information about people's health and well being could be retrieved quickly.