The Brambles Rest Home

The Brambles Rest Home is a residential care home providing personal care to 25 people aged 65 and over at the time of the inspection. The service can support up to 32 people in one adapted building.

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

People received care and support in a clean and homely environment. Recruitment processes were followed to help ensure only suitable people were employed and staffing was arranged to ensure people’s needs could be met. Medicines were managed safely, and accidents and incidents were reviewed, and action taken to minimise the risk of reoccurrence.

Care records contained risk assessments and person - centered information to ensure staff knew how to promote people’s safety. These were reviewed and changes made if this was needed. People were consulted and asked their views on the service provided. Surveys had been completed by people who lived at the home and meetings were held where people could share their views. Audits and checks were carried out and action plans developed to drive improvement.

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 16 July 2021). We recommended the provider implement best practice guidance in relation to medicines management and person-centered record keeping. At this inspection we found improvements had been made.

Why we inspected

This was a focused inspection based on the previous rating. 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.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Lancashire and South Cumbria. To understand the experience of social care Providers and people who use social care services, we asked a range of questions in relation to accessing urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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 requires improvement to good based on the findings of this inspection.

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

Follow up

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

The Brambles Rest Home is a residential care home providing personal care to 11 people aged 65 and over at the time of the inspection. The service can support up to 32 people in one adapted building.

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

People could not be assured medicines were always managed safely as improvements were required. We have made a recommendation about the safe management of medicines. Records did not always reflect the individual symptoms and help and support people needed if their health condition changed. We have made recommendations about the recording of unique information relevant to individuals. These recommendations can be seen in the Safe section of this report. Some equipment required adjustment to help ensure it met people's needs. The provider introduced additional checks to minimise the risk of reoccurrence.

Staff were effectively deployed so people received support when they needed it. Risk assessments were carried out to minimise the risk of avoidable harm and staff knew the help and support people required.

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.

People were cared for in a safe, clean and homely environment by staff who were caring, competent and knowledgeable about people’s needs. Staff told us training and supervision was arranged to ensure staff had the skills to carry out their role. People told us they were happy at the home and they felt cared for. They explained the food was good, enjoyable activities were arranged, and they were supported to access medical advice if they needed this.

People were treated with dignity and respect and staff we spoke with us told us how they respected people and ensured their privacy and dignity was maintained. Care was person centred, met people's needs and achieved good outcomes. People were cared for at the end of their life in line with their wishes.

Staff told us they felt supported by the management team and they were able to approach them if they needed support and guidance.

People were consulted and asked their views on the service provided. Surveys had been completed by people who lived at the home. People told us they were confident any comments or complaints they made would be listened to. However, audits and checks did not always identify the shortfalls we found on the inspection.

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 inadequate (published 1 January 2020) and there was a breach 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 improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since December 2019. During this inspection the provider demonstrated improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating. 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.

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

We have found evidence that the provider needs to make more improvements. Please see the safe and well-led sections of this full report.

The management team took swift action during the inspection process to reduce risks and improve the service.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

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

Medicines were not always managed safely. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment.) Records did not consistently reflect the help people need and audits did not always identify when improvements were required. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good governance.)

Recruitment procedures were followed to ensure staff were suitable to work with people who may be vulnerable. People were supported by staff who responded to their needs quickly, however we received feedback that there were times when an extra staff member would have been helpful. We have made a recommendation about the deployment of staff.

People said they were happy at the home and they liked the staff. People were cared for in a clean and homely environment by staff who were caring, competent and keen to improve the service provided. Risk assessments were carried out and staff could explain the reason for the assessments and how they followed them to help keep people safe.

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.

People’s rights were upheld, and people received health professional advice when this was needed. The manager and staff worked with other agencies to improve the service provided.

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 inadequate (published 14 December 2019) and there were multiple breaches of regulation. At this inspection we found improvements had not been consistently made and the provider was still in breach of regulations.

This service has been in Special Measures since December 2019. The overall rating for this service is ‘Inadequate’ and the service remains 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.

Why we inspected

We carried out an unannounced comprehensive inspection of this service in September 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve in the areas of safe care and treatment, person – centred care, need for consent, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, fit and proper persons employed, staffing and good governance.

We undertook this focused inspection on 14 September 2020 to check they had followed their action plan and to confirm whether they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. At this inspection we found improvements had not been consistently made and the provider was still in breach of some regulations.

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 the service can respond to coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains inadequate. This is based on the findings at this inspection.

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

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 remains inadequate. This is based on the findings at this inspection.

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 the safe management of medicines, record keeping and good governance.

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

Follow up

The overall rating for this service is ‘Inadequate’. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. In addition, 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.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

The Brambles Rest Home is a residential care home providing personal care to 23 people aged 65 and over at the time of the inspection. The service can support up to 32 people in one adapted building.

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

There were inadequate processes in place to protect people from the risk of avoidable harm. Staff had not carried out effective risk assessments in relation to people they supported and the environment.

We could not be sure people always received their medicines as prescribed because medicine management practices were not consistently safe. Some staff who administered medicines were not competent to do so and this placed people at risk of harm.

Some staff did not understand how to protect people from abuse or unfair treatment. The provider failed to maintain a positive culture that promoted reporting and acting on people’s concerns.

Staff were not always recruited in a safe way. Staff told us staffing levels were sufficient to meet the needs of people who lived at the service however, the provider failed to evidence how staffing numbers were decided.

Infection control processes were inadequate and placed people at risk of infection through cross-contamination. Staff did not always have access to hand washing facilities and failed to follow safe practices when handling clinical waste.

There were insufficient numbers of suitably trained and competent staff. Staff had not always received adequate induction training before being allowed to support people in an unsupervised environment. This placed people at risk of avoidable harm. Staff had not been regularly supervised or appraised.

People’s physical, mental health and social needs were not consistently assessed. Staff failed to adequately risk assess and care plan the needs and preferences for people on short term or respite care. Staff did not consistently involve people in the care planning process.

The provider failed to ensure people had access to a wide range of nutritious and good quality food. Staff did not consistently support people to have choice and control at meal times. People did not have free access to snacks or fresh fruit.

People were not always supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not support this practice.

Two visiting professionals told us the registered manager and staff supported people in an effective and responsive way. People’s care records showed they were referred to specialist departments for example; dietician, speech and language and physiotherapy. However, there advice was not always included in people’s care plans.

People told us they were supported by kind and respectful staff. Staff engaged with people in a kind way and had built trusting relationships. Relatives told us they were happy with the care and support people received. The provider had not asked for feedback from people and other stakeholders.

People did not always receive support in a person-centred way. People’s care records were not person-centred, this meant staff did not have up to date information to guide them about how best to support people.

People’s end of life needs and preferences were not always assessed in a timely way before their health needs deteriorated. This meant in the event of a sudden death staff would not always be aware of people’s preferences. Relatives and external professionals provided positive feedback about how people were supported at the end of life.

The service was not well-led. The provider failed to ensure good outcomes for people and adequately quality assure the service. Some staff did not feel confident to approach or confide in the registered manager and this had a negative impact on the culture throughout the service.

The registered manager had resigned from their position but maintained their registration. The provider had taken steps to recruit a new manager, however this person had also resigned before the inspection. During the inspection the provider appointed an interim consultant management team.

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 06 September 2018) 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 improvements had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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

Enforcement

We have identified breaches in relation to safe care and treatment, safeguarding, consent, person-centred care, nutrition and hydration, staff training and support, governance and staff recruitment.

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.

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.

The Brambles Rest Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates 32 people. At the time of the visit there were 25 people who received support with personal care. Nursing care is not provided at this service.

The service was managed by a registered manager. 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.

At the last inspection in January 2016, the service was rated ‘good’.

At this inspection in July 2018 we found shortfalls in relation to medicines management, safety checks, staff training and development, and good governance management. We found breaches of Regulations 12,17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines management practices in the home were not robust and staff had not received up to date training and competence checks. Emergency lighting inspections had not been undertaken in line with regulations. The governance and quality assurance systems were not effective in ensuring the shortfalls were identified and rectified before the inspection. You can see what action we told the registered provider to take at the back of the full version of the report.

Improvements were required to the management of medicines in the home. People told us they received their medicines as prescribed and some staff had been trained in the safe management of medicines. However, we noted that further improvements were required to ensure people’s medicines were robustly managed. Medicines audits were not effectively identifying shortfalls and areas of improvement. There were shortfalls in the medicines storage practices and the management of ‘as required medicines’ were not robust.

Some of the staff had received induction and training. However, there were significant shortfalls in staff training and competence checks in various areas. The training policy needed to be reviewed to ensure it was up to date with current regulatory requirements.

The registered manager and registered provider used a variety of methods to assess and monitor the quality of care at The Brambles Rest Home. There were checks in various areas such as medicines administration, health and safety and infection prevention and control. However, we found the internal audit and quality assurance systems needed to be improved in areas such as medicines management staff training to ensure they could effectively identify areas of improvement and any shortfalls to the quality of the service. There were policies and procedures in place. However, some of these needed to be reviewed to ensure they were in line with current guidance and regulations. There was no evidence on how the registered provider had checked that registered manager was compliant with regulations. They informed us of the plans they are introducing in respect of this.

We received positive feedback from people and their relatives regarding the quality of care and staff approach. Views of a professional we spoke with were also positive. People who lived at the home told us that they felt safe. There was mixed feedback about the staffing levels in the home from visitors and visiting professionals. Visitors and people who lived at the home spoke highly of the registered manager and the care staff.

Staff knew how to report concerns to safeguarding professionals however 15 out of 19 did not have up to date safeguarding training. Accident and incidents had been recorded and medical attention had been sought where required. Recruitment checks were carried out to ensure suitable people were employed to work at the home.

Risk assessments had been developed to minimise the potential risk of harm to people who lived at the home. These had been kept under review.

The staff who worked in this service made sure that people had choice and control over their lives and supported them in the least restrictive way possible. People’s consent to various aspects of their care was considered and where required some deprivation of liberties (DoLS) authorisations had been sought from the local authority. Some improvements were required to ensure all mental capacity assessments were decision specific. We made a recommendation about mental capacity practices and the registered manager started to act to address this.

Risk associated with fire had been managed and fire prevention equipment serviced in line with related regulations. However, improvements were required as there was no up to date emergency lighting inspection report. Risks of infection had been managed. The environment was clean, and adaptations and decorations had been used to suit the needs of people living in the home.

Care plans were in place detailing how people wished to be supported. People and their relatives were involved in care planning. People’s independence was promoted. There was a policy on how to prevent discrimination and promote equality and diversity.

The provider had sought people’s opinions on the quality of care and treatment being provided. Relatives and resident’s meetings and surveys had been undertaken to seek people’s opinions however these had not been analysed and feedback on the outcome of the survey had not been shared with people.

We observed that regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration. People’s nutritional needs were met. Risks of malnutrition and dehydration had been assessed and monitored. Comments from people who lived at the home were all positive about the quality of meals provided.

We found people had access to healthcare professionals and their healthcare needs were met. Relevant health care advice had been sought so that people could receive the treatment and support they needed. Health and safety concerns were identified and rectified.

On the day of inspection people were not offered meaningful daytime activities. However, there were plans of activities and activities that had been offered before the inspection. We were informed that the activities co-ordinator was away on the day. People were supported to continue to access their community to reduce social isolation.

People who used the service and their relatives knew how to raise a concern or to make a complaint. The complaint’s procedure was available, and people said they were encouraged to raise concerns. However, records of complaints received in the home were not made available to us on the day of the inspection. The provider informed us they had not received a complaint since our last inspection.

Staff told us there was a positive culture within the service. Staff we spoke with told us they enjoyed their work and wanted to do their best to enhance the experience of people who lived at the home. We received positive feedback from two visiting professional and relatives of people who lived at the home.

We saw evidence where the registered manager and staff had considered best practice.

At our last inspection on 08 & 09 May 2014, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 relating to; Care and welfare of people who use services (Regulation 9), Staffing (Regulation 22), Assessing and monitoring the quality of service provision (Regulation 10) and Records (Regulation 20). Following that inspection, we received an action plan from the provider which explained changes they planned to make to improve the experience of people who used the service.

During this inspection, we looked at whether the provider had made the changes they had planned and whether they had improved the standard of the service provided. We found the changes that had been implemented had resolved the issues we identified at our last inspection.

The Brambles Rest Home is a large detached residence, situated in a residential area of New Longton near to the city of Preston. The home provides 24 hour personal care and accommodation for up to 32 older people. All bedrooms have ensuite toilet facilities, some have showers and there are five different communal areas. There is a passenger lift to the first floor and all areas are wheelchair accessible. There are extensive gardens with outdoor seating areas and a large car park.

The service had a long-standing registered manager in post. 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 experienced safe care and support form staff that had been properly recruited and were skilled and knowledgeable. The service identified and managed risks to people's health, safety and well-being and kept them under review.

The service had systems and processes in place to ensure the safe management of medicines. Staff who administered medicines had been trained appropriately and their competence checked. A quarterly visit from the local medicines optimisation team took place, with the aim of improving the overall experience for people who received medicines at the home.

Staff received regular one-to-one supervision sessions with the registered manager to discuss performance, training, aspirations and other topics. Staff told us they felt well supported by the manager and had access to the training they needed.

People were complimentary about the selection and the quality of the food provided. We saw people enjoyed the mealtime experience.

People were able to access external healthcare services, such as dentists, doctors and chiropodists, which helped to maintain their overall healthcare needs.

The staff team were described as 'friendly', 'kind' and 'caring'. We saw that people's privacy was respected and dignity promoted by staff at the service. However, there were occasions when staff seemed to be rushing to complete tasks which affected the quality of interactions with people in their care. The provider assured us they would address this following our inspection.

People were involved and consulted with regard to planning their care and had their individual needs and preferences taken into account in the way care was delivered. Regular review of people's needs and plans of care helped to ensure that the care delivered was safe and suitable for them.

Feedback from people who used the service, their relatives, staff and visiting professionals was sought via a range of means. The feedback we saw and were given by people we spoke with was complimentary. The provider had implemented a suitable complaints procedure and people knew how to raise concerns or complaints.

The service was led by an experienced manager, with a committed staff team. This helped the service to look toward continuous improvement of the experience of people who used the service. A range of safety and quality checks were employed by the manager to identify and address any shortfalls in the quality of the service provided to people.