Briarcroft Care Home

Briarcroft Care Home is a residential care home providing care and accommodation to up to 21 people. The service provides support to older people living with dementia. At the time of our inspection there were 20 people using the service.

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

Environmental risks were not always identified or well managed. Some risks relating to fire safety had not been identified, the premises and equipment were not well maintained and in parts the premises was in poor repair, and visibly dirty. Governance systems had failed to identify the concerns identified at this inspection.

Following our site visit, we contacted the fire service with our concerns. They inspected the premises and made 7 recommendations the provider should address to ensure compliance with fire safety requirements. The provider assured us they would take action to address fire safety concerns and the maintenance issues identified.

Whilst there was no evidence people had been harmed, people were at potential risk of harm. This was because records didn’t always evidence care being provided in line with individual care plans, risk assessments had not always been completed, and staff had not completed training specific to people’s needs.

There were a range of risk assessments in place, and they were regularly reviewed. Some individual risks were very well managed. For example, staff were skilled at managing risks around people’s behaviours, particularly when people were experiencing significant distress and agitation. One visiting health professional told us they were supporting a person who had 3 previous placements terminated due to their behaviours. They said, “Briarcroft have worked so hard, with the support of the [health professionals] Team, on finding strategies that work for [person’s name]. Systems and processes to protect people from abuse were in place and being operated effectively. Staff and people’s relatives told us they felt comfortable raising concerns. Staff were recruited safely, and there were enough staff to meet people’s needs. People received their medicines safely and there were good medicines management systems in place. Incidents and accidents were analysed on a regular basis and any themes or patterns identified.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The culture of the service was open and inclusive, and staff worked with other professionals to ensure people achieved good outcomes. All the relatives we spoke to gave positive feedback about the staff team. Comments included, “From the first time I stepped into Briarcroft, it felt like a blanket of love”. “I don’t have enough good words to say. They are brilliant. It’s like a real home”. And, “They’re wonderful, been fantastic, like a family to me. [Relative] is so happy”. Staff supported several people who had failed placements elsewhere. They were non-judgmental about how people expressed their emotions and worked with people and professionals to develop positive strategies to support people.

Staff were keen to continuously learn and improve care and sought opportunities to engage with external professionals to do so. Two senior staff had volunteered to take part in a hydration pilot project with a view to improving hydration and reducing urinary tract infections and falls. In December 2021 they were awarded a silver award in recognition of their work. The service had also engaged in a research project with Plymouth University looking at what constituted good quality care across a range of services. Health care professionals highlighted how open the service was and how keen they were to improve. One said, “They genuinely have people’s best interests at heart”. The registered manager sought feedback from people’s relatives both informally and via an annual survey. The provider collated the responses and we saw people’s relatives openly shared both positive and constructive feedback.

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 good (22/02/2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service and the length of time since we last rated the service.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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.

You can see what action we have asked the provider to take at the end of this full report.

The provider has taken action to address the concerns identified at this inspection, including engaging an external fire safety company to complete a professional fire risk assessment.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Briacroft Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to premises and equipment, safe care and treatment and good governance at this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Staff had ongoing training in infection control and effective use of personal protective equipment (PPE). They had an accessible file to refer to with all policies and the latest up to date guidance on testing, visiting and rules in relation to being positive for COVID-19.

There were clear guidelines and checklists to ensure cleaning was completed to a high standard. This included touch points having additional cleaning throughout the day. Furniture in communal areas had been replaced with wipe clean fabric furniture to ensure all chairs and seating could be cleaned daily.

The service had followed government guidelines in respect of visiting. They had a conservatory where families could meet their relatives if they wished. People living at the service were unable to give their views on whether they had seen their relatives frequently. We spoke with five relative who confirmed processes were in line with government guidelines. One relative said “They have done their best to keep people safe and balance the need for them to see us. When we were unable to visit they were very good with video and phone calls, regular newsletters and setting up a Facebook page.”

Staff were seen to wear PPE at all times and relatives said their observations were that staff wore masks at all times.

The service had developed a good testing regime for people, staff and visitors. They had a record of all staffs vaccinations to show they were compliant with this being a condition of employment. Similarly, they had a process in place to check any visiting professionals had been vaccinated and were testing for COVID-19.

This inspection was unannounced and took place on 14 and 15 December 2017. The last comprehensive inspection of the service was in August 2016. At this inspection we found breaches of regulations related to person centred care, dignity and respect, the protection of people’s legal rights, safe care and treatment, premises and equipment and quality monitoring. We rated the home as ‘Requires Improvement’ in all five key questions. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider. This required the provider to improve quality monitoring processes by 7 November 2016, due to the serious and major impact on the safety and quality of services people received. We issued requirements for the other five breaches of regulations. Following the inspection in August 2016 we met with the provider who gave assurances of their commitment to improving the quality and safety of the care and support provided to people.

We carried out an unannounced focused inspection on 13 January 2017 to check that improvements to meet legal requirements planned by the provider after our August 2016 inspection had been made. The team inspected the service against one of the five questions we ask about services, “Is the service well led?” We some found improvements had been made. The provider had developed a service improvement plan, with the support of the local authority’s quality and improvement team, and begun a programme of improvements within the home. However, we found there were other areas that required improvement and some of the decisions made by the manager did not promote safety or protect people’s rights. We identified breaches of regulation related to safe care and treatment and safeguarding service users from abuse. Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question, “Is the service well led?” to at least good.

At this inspection in December 2017 we found significant improvements had been made and the key question, “Is the service well led?” was now rated good. There was a new manager who registered with the Care Quality Commission to manage the service on 11 August 2017. Like registered providers, registered managers 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, relatives, staff and external health and social care professionals spoke highly of the registered manager and the positive changes that had been made at Briarcroft in the short time they had been in post.

The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong. They had acknowledged the areas in which the service needed to develop and improve, and, working closely with the local authority quality and improvement team, had been proactive in making this happen.

There were quality assurance systems in place to help assess the safety and quality of the service, and identify any areas which might require improvement. The findings of the audits informed a service improvement plan, with clearly defined actions, responsibilities and timescales. The views of people, their relatives, and staff were actively sought to ensure the service was run in the way they would like it to be.

People told us they felt safe and there were sufficient numbers of staff deployed to meet their needs. Regular health and safety checks were undertaken at the service. There were effective infection prevention processes in place, the home was now compliant with fire regulations and a programme of refurbishment was in progress which meant people were now protected from risks posed by the environment. There were systems in place to ensure risk assessments, care plans and reviews were comprehensive, current, and supported staff to provide safe care while promoting independence. People were protected from the risk of abuse through the provision of policies, procedures and staff training, and an effective recruitment process. People received their medicines safely.

The registered manager had been working hard to develop a person-centred service and their values were shared across the staff team. Staff promoted people’s independence and treated them with dignity and respect. They were supported to make choices about their day to day lives, for example how they wanted their care to be provided and how they wanted to spend their time. People and their relatives contributed to the drawing up and reviewing of care plans which meant they reflected people’s individual preferences. One member of staff told us, “I didn’t know what person centred meant before the registered manager came here. We used to get them all up at the same time, now we get them up when they want to get up.” Staff understood the importance of meaningful communication in helping people to make choices and express their views, and were mindful of the need to ensure information was given to people in accessible formats when required. For example, people were able to give their views of the service in a service user questionnaire which contained pictures as well as words. Staff adapted their communication methods dependent upon people’s needs, using body language or simple questions and information for people with cognitive difficulties.

There was a committed staff team at the home which was well supported by managers and the providers. An induction and training programme was in place which enabled them to do their jobs effectively, and they received regular supervision, both formal and informal. Ongoing professional development was encouraged for all staff members. The registered manager was proactive in keeping their own knowledge and skills up to date, attending workshops and events, and sharing ideas about best practice with the manager and staff of a nearby residential home. This meant people received effective care and support from staff with the experience, skills and knowledge to meet their needs.

We checked to see whether people’s human rights were now protected under the Mental Capacity Act 2005 (MCA). We found people’s rights were protected because the registered manager and staff had an understanding of the MCA and Deprivation of Liberty Safeguards (DoLS) and had applied the principles to their practice.

People had sufficient to eat and drink and received a balanced diet. People’s individual dietary needs were assessed and the service was committed to meeting any dietary requirements related to health or culture. Where there were concerns about a person’s nutritional intake advice had been sought from relevant health professionals who had provided guidance.

People were supported to maintain good health and had access to health and social care services. People were referred appropriately and guidance followed. A relative commented, “They are really good at involving health professionals, and quick to get somebody to come and assess”.

Improvements had been made in relation to the adaptation of the environment to support people living with dementia. For example clear signs and pictures helped people to orientate themselves and move independently around the home.

This focused inspection took place on 13 January 2017 and was unannounced. The inspection was undertaken to review the progress the provider had made with meeting the requirements of the warning notice issued following the comprehensive inspection of the home in August 2016. At that inspection we rated the home as requiring improvement in all five of the key questions. We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the quality and safety of the services provided.

The home was obliged to have a registered manager in post as this was a condition of the provider’s registration with us. The provider had appointed a new manager following the previous inspection. They confirmed they were in the process of applying to register with us. Following the inspection, the provider confirmed the manager had submitted their application to registered with us. 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.

Following the inspection in August 2016 we met with the provider who gave assurances of their commitment to improving the quality and safety of the care and support provided to people. At this inspection in January 2017 we some found improvements had been made. The provider had taken action to commence a programme of improvements within the home and had been visiting each week. The manager had been working with the local authority’s quality and improvement team and had developed a service improvement plan. However, we found there were other areas that required improvement and some of the decisions made by the manager did not promote safety or protect people’s rights.

Broken and unsuitable furniture had been replaced and equipment had been serviced. A programme of refurbishment and redecoration was underway. The manager confirmed the laundry room would be redecorated as the paint was peeling from the walls which made this room difficult to keep clean. The manager said this room had been identified by the provider as requiring redecoration and this would be undertaken shortly: it had been identified as requiring repainting in the refurbishment plan.

We found equipment in use that placed people’s freedom of movement and their safety at risk. A gate had been placed across part of the hallway on the first floor which restricted access to two people’s bedrooms. This use of the gate had not been properly assessed or authorised and as such its use was an unauthorised restriction of people’s liberty. We also found a portable ramp was being used to bridge the gap between two sets of steps. The use of the ramp had not been assessed as safe to use. The manager removed the gate and the ramp immediately.

At the previous inspection we identified that care planning records were insufficiently detailed to identify people’s care needs and how they should be supported. Since then the home had introduced a computerised care planning system. Each person had a newly competed care plan. However some improvements were still required. For example, people’s preferences in how they wished to be supported were not recorded. In September 2016 the manager had sent questionnaires to people to gain their views about the quality of the care and support in the home: we saw the results of these were favourable about the care being provided. A thank you letter from a relative was received by the home on the day of the inspection.

We made a recommendation for improvement and identified two breaches 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 the report.

Briarcroft Care Home was registered to provide care for up to 20 people. People living at the home were older people, the majority of whom were living with dementia.

The home did not have a registered manager. Although there was a manager in post, they had not yet completed their registration with the Care Quality Commission, and are therefore referred to as the manager throughout this report. 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.

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Briarcroft Care Home was last inspected on 8, 10, and 13 July 2015. The home was rated as good across all key questions at that time. This inspection on 1 August 2016 was bought forward because we had received information of concern about the home since the last inspection, including about cleanliness, people being got up early, general care of people and a recent safeguarding concern about a person with a pressure ulcer.

On this inspection of 1 August 2016 we identified a number of concerns about the home, including issues around cleanliness and infection control, management and leadership, care planning, systems for managing quality and risk and a lack of action with regard to protecting people’s rights under the Mental Capacity Act 2005.

Risk assessments were not always in place or did not contain enough information to help keep people and others safe from risks associated with their care. This included concerns about the monitoring of people’s food and fluid intake where they had been assessed as being at risk, and support to help people with distressed or risky behaviours.

The environment was not always safe for people. We identified risks from the furnishings, equipment, poor cleanliness, and poor infection control. Some areas of the home were not being cleaned regularly or thoroughly, and stained or torn cushions and chairs were evident both in communal areas and in people’s rooms. Some areas were visibly dirty, and care and attention was not always being paid to quality issues such as making beds properly to help provide a comfortable environment for people to live in.

People’s rights under the Mental Capacity Act 2005 were not always being respected and applications had not been made for Deprivation of Liberty Safeguards where needed. Best interest decisions had not always been recorded. However staff had a good understanding of capacity and consent issues in day to day practice. Staff understood how to report concerns about people’s well being and welfare. Systems were in place for the management of complaints.

People were not always being protected from the risks associated with medicines, for example we found some prescriptions creams had been left out in people’s bedrooms. Other areas of medicines practice was well managed, and people received the medicines they were prescribed appropriately. People had access to the community healthcare services they needed, including medical specialists and community nurses.

There were enough staff on duty to meet people’s physical care needs on the day of the inspection, although staff told us that at times this was ‘tight’ dependent on people’s changing behaviour or needs. Staff were able to respond to people’s planned needs and care tasks, but people were left alone in the lounge and unobserved for periods, and there was a lack of dedicated time to support people socialise or engage with activities. The manager did not have a system to identify the number of staff needed based on the dependency level of the people at the home. We have made a recommendation about keeping staffing levels under review to ensure they meet people’s needs.

A full staff recruitment process had been followed for two out of the three staff files we saw. The manager agreed to ensure the other file was completed retrospectively as the person had already started work at the home. We have made a recommendation that the registered person ensures safe recruitment practice is followed for each staff member.

Staff received training and had observations carried out of their practice. But where issues had been identified regarding staff performance we could not find evidence that this was followed up, so it was not possible to see what improvements had been made. We have made a recommendation about this.

Meals served to people were not always varied or well planned, although we did see people being offered choices. Where there were concerns over people’s swallowing, advice and assessment had been sought from appropriate healthcare staff. But this information was not always easy to find in people’s files and the home had not undertaken a choking risk assessment for people.

The building was not well adapted to meet the needs of people living with dementia. Information was not always provided to help people maintain their independence or orientate themselves to their environment. We have made a recommendation about this.

We saw evidence of some positive relationships in place, and caring interactions between staff and people living at the home. But we also saw instances where people’s dignity was not always supported and staff did not always treat people with respect. For example people’s dress and self-care needs were not always being followed.

Care planning information was not always clear and did not always contain information from people on their preferences regarding their care. There were no clear and consistent plans for activities to help with supporting people to remain active and reduce risks from social isolation. Care plans focussed on people’s physical needs, and had little information about the impact of dementia on people’s day to day lives. The home did not use specialist tools for assessing the needs of people with dementia, for example pain assessment tools to support people who had limited verbal communication.

Leadership was poor and management had not been effective at identifying quality and safety concerns or addressing them. Where action plans had been drawn up in 2015 to make improvements, actions identified had not been completed or had not been effective in making the changes needed.

Records were not all well maintained. Care records did not always reflect people’s needs or wishes consistently. Management records including audits were not completed and the manager could not locate some we asked for. Policies and procedures had been marked as being updated in 2015, but referenced out of date legislation or other care homes. This told us they had not been updated thoroughly, and would not offer the most recent guidance for staff.

We identified a number of breaches of regulation on this inspection. You can see what action we told the provider to take at the back of the full version of the report.