20 February 2021
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.
As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place.
This inspection took place on 3 February 2021 and was announced.
20 February 2021
Bryher Court Nursing Home is registered to provide nursing care for up to 45 older people. There were 24 people living at Bryher Court at the time of the inspection. People required a range of care and support in relation to living with memory loss, dementia, nursing and personal care needs. Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two lifts. This was an unannounced inspection which took place on 23 October 2017.
In March 2016 and December 2016 the overall rating for this service was Inadequate and we took enforcement action against the provider and placed the service into Special Measures. Special Measures means a service is kept under review and if needed urgent enforcement action can be taken. The local authority put a restriction on admissions to prevent the service from admitting people until improvements were made. On the 3 and 4 July 2017 we inspected to see if improvements had taken place. The service was rated as Requires Improvement with enforcement action still in place whilst we continued to monitor the service to ensure that improvements continued and became part of the integral systems and processes. At this inspection we found improvements had been made and we have withdrawn the enforcement action previously issued. The provider is now meeting all regulations. We will continue to monitor the service to ensure this level of service is maintained.
The registered manager had left employment at the home but was currently still registered with CQC. The deputy manager had been acting as manager supported by a consultant employed by the provider and the provider, who was present at the home on an almost daily basis. A new manager had been recruited and they had started work the week prior to this inspection. We were told by the provider the newly recruited manager would be registering with CQC. 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 and associated regulations about how the service is run.
Documentation had been greatly improved with new care plan formats introduced. Care plans were detailed and person centred. Staff had information that enabled them to provide support in line with people’s wishes. Personal and environmental risk assessments took place to ensure people’s safety was maintained. These included risks assessments for people’s specific individual risks and regular maintenance and safety checks for services and equipment. Monitoring and documentation of accidents, incidents and falls was robust. Staff had a good understanding of safeguarding and were able to tell us how they would report a safeguarding concern.
There were systems to assess quality and identify any potential improvements to the service. This included a robust programme of audits completed on a regular basis. All audits included analysis and actions and had been signed and dated when actions had been addressed. Safe medicine procedures made sure people received their medicines consistently and safely. Systems were in place to ensure medicines were ordered, stored and disposed of appropriately. People’s nutrition and health was monitored. Meal choices were available and we received good feedback regarding the meals provided. People's weights were monitored and any changes reported.
Relatives felt that communication was good and they were always contacted if needed.
There was a complaints policy and procedure at the home. People were aware how to raise any complaints or concerns and told us they would be happy to do this if needed. Staff told us they supported people to discuss any issues.
People were supported by staff who were kind and caring. Staff respected people's dignity and right to privacy and knew people well. People were encouraged to participate in meaningful activities and to continue with hobbies that they had previously enjoyed. Staff were aware of how people they liked their care to be provided. Decisions regarding people’s consent and capacity had been assessed and recorded. Staff understood the importance of involving people in decisions and encouraging and supporting people’s independence when possible. People were supported to attend appointments and referrals were made to other health professionals when needed.
Recruitment processes were being followed to make sure required checks took place before people began work at the home. Staff received appropriate training and training was monitored to ensure it was kept up to date. Staff competencies were assessed and there was an on-going programme for staff to receive supervision. Regular meetings took place for staff to ensure they were kept informed of changes and developments. Residents, relatives and visiting professionals also provided meaningful feedback all of which was analysed and used to take the service forward and encourage improvement. People, relatives and staff spoke positively about Bryher Court Nursing Home and the on-going improvements.