Archived: Brackenfield Hall

Our last inspection at Brackenfield Hall took place on 2 August 2016. The home was rated Requires Improvement overall. We found the service was in breach of four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. The registered provider sent us an action plan detailing how they were going to make improvements. At this inspection we checked the improvements the registered provider had made. We found sufficient improvements had been made to meet the requirements of these regulations.

We carried out this inspection on 23 October 2017. The inspection was unannounced. This meant the home’s staff and management did not know the inspection was going to take place.

At the time of our inspection the home had a registered manager in post. A registered manager is a person who has registered with the 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.

People spoken with were very positive about their experience of living at Brackenfield Hall. They told us they were happy, felt safe and were respected.

Whilst staff told us they were provided with regular supervision, we found staff supervisions were not always recorded. Since this inspection the registered provider submitted an updated supervision matrix. This showed all staff had received regular supervision or were due to receive supervision.

We found systems were in place to make sure people received their medicines safely so their health needs were met. Medicine protocols were in place to guide staff when to administer medicines prescribed on an ‘as and when’ basis to meet people’s health needs.

Staff recruitment procedures were in place. The registered provider ensured pre-employment checks were carried out prior to new staff commencing employment to make sure they were safe to employ.

Staff were provided with relevant training, which gave them the skills they needed to undertake their role.

Sufficient numbers of staff were provided to meet people’s needs. We saw staff responded in a timely way when people required assistance.

People’s care records contained detailed information and reflected the care and support being given.

The service provided a programme of activities to suit people’s preferences. We observed activities taking place and feedback from people who used the service was positive.

Staff knew people well and positive, caring relationships had been developed. People were encouraged to express their views and they were involved in decisions about their care. People’s privacy and dignity was respected and promoted. Staff understood how to support people in a sensitive way.

There were systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the registered provider’s policies and systems supported this practice.

Brackenfield Hall is a care home without nursing, which is registered to provide accommodation and personal care to a maximum of 60 older people, some of whom may be living with dementia. The service is accommodated in a purpose built building which was first developed into a care service seven years ago. The service is provided over three floors; the first two floors are split into four units; on one side of the building (ground and first floor) are two units called Endcliffe, which accommodate people living with dementia. On the other side of the building are two units both called Rivelin and on the ground floor is the unit for residential care and on the first floor a unit for people living with dementia. The second floor level is used for the kitchen, laundry and staff area. At the time of our inspection there were 59 people in residence, 46 of whom were living with dementia.

The registered provider is required to have a registered manager in post and there was a registered manager at this service. 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.

During our inspection we found that recruitment procedures were not robust and did not follow the registered provider’s policy and procedure. This is a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found there were some inconsistency within the fire and emergency practices and procedures within the service. This potentially put people at risk of harm as staff did not have the skills and knowledge to evacuate people safely should there be a fire in the home. This is a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that the induction, supervision and support for new staff was not robust and did not adequately enable them to carry out the duties they were employed to perform. This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Record keeping within the service needed to improve. We saw evidence that care files and risk assessments were not always accurate or up to date. This meant that staff did not have access to complete and contemporaneous records in respect of each person using the service, which potentially put people at risk of harm. This is a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

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

People told us that they felt safe living at the home. We found that staff had a good knowledge of how to keep people safe from harm and there were enough staff to meet people’s needs. People received their medicines safely and where errors were noted the registered manager took appropriate action to improve staff practices.

Some people who used the service were subject to a level of supervision and control that amounted to a deprivation of their liberty; the registered manager had completed a standard authorisation application for each person and these had been reviewed by the supervisory body of the local authority. This meant there were adequate systems in place to keep people safe and protect them from unlawful control or restraint.

People were able to talk to health care professionals about their care and treatment. People told us they could see a GP when they needed to and that they received care and treatment when necessary from external health care professionals such as the District Nursing Team or Diabetic Specialists.

People had access to adequate food and drinks and we found that people were assessed for nutritional risk and were seen by the Speech and Language Therapy (SALT) team or a dietician when appropriate. People who spoke with us were satisfied with the quality of the meals.

People spoken with said staff were caring and they were happy with the care they received and had been included in planning and agreeing the care provided. They had access to community facilities and most participated in the activities provided in the service.

People knew how to make a complaint and those who spoke with us were happy with the way any issues they had raised had been dealt with. People had access to complaints forms if needed and the registered manager had investigated and responded to the five minor complaints that had been received in the past year.

The registered manager monitored the quality of the service, supported the staff team and ensured that people who used the service were able to make suggestions and raise concerns. We saw from recent audits that the registered manager was making progress in improving the quality of the service.