Breach House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of a legal regulation in relation to safe care and treatment.

This service scored 42 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Reviews of care planning documentation were not carried out with people or their representatives.

Staff completed assessments when people moved to the service, to assess any risks and help develop their care plans. We observed a lack of thorough assessment of people’s needs and risks to them. People’s needs assessments did not focus on people’s strengths. Care plans were not always detailed, with a lack of information to reflect changes in people’s needs such as their mobility or specific health conditions resulting in gaps in the information available to staff. This meant staff did not have guidance to effectively deliver people’s care safely.

Where people required support with repositioning, assessments did not contain information for staff to follow about the risk, or mitigation, such as how often people should be supported to reposition and what equipment would be needed. Staff we spoke with knew how often people should be supported to reposition, but reported people didn’t always get this in a timely manner on evenings and weekends when there were less staff available on those shifts. People’s care notes evidenced they were using equipment which had not been included within their assessments.

Assessments in place did not always have the correct scoring or information which could impact the support people receive. Peoples care records were not updated following incidents to mitigate the risk, this meant staff did not have the most accurate information to support people’s care needs. Staff told us they were not always updated if people’s needs changed.

People were put at increased risk as care plans and risk assessments were not person centred or accurate.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. People were not always told about current good practice that was relevant to their care, nor were they meaningfully involved in how this was reflected in their care plans. We asked people if they were aware of having a care plan. People said, “I don’t think so, but I think staff know me and what they [staff] need to do" and “never had a chat about likes and dislikes, I just sit in this chair and wait for them [staff] to tell me what to do”.

Some people were living with dementia however, the environment was not always dementia friendly, as signage around the home was unclear.

People were offered a choice of meals and were mostly positive about the food. People told us, “Depends how busy they are how many drinks are offered” and “Meals depends, mainly okay, not particularly much choice, take order day before, chef very nice man, teatime always get sandwiches”. However, we were concerned staff had not always provided food at the correct texture to meet a people’s assessed needs. One person required a modified diet to reduce their risk of choking. However, records suggested staff had provided meals and snacks which were not in line with this assessment. We found guidance provided to staff in the kitchen was not up to date and staff were not fully aware of the consistency of food and fluids people required. The deputy manager took action to address this straight away when we raised this on our second site visit. When we returned for our final site visit, we found care records had still not been updated by the manager to accurately reflect people’s specific dietary needs and continued to contain conflicting information.

Waterlow scores (a nationally recognised risk assessment tool to identify people at risk of developing pressure ulcers) were not always completed correctly which posed a risk to people as it was not always clear if people were at high or low risk of skin breakdown.

Different area of people’s care plans contained contradictory information, which meant that guidance for staff on how to deliver people’s care was not accurate. Reviews were not always undertaken as frequently as required where people were at risk.

When our inspection team enquired how the manager ensures their own practice is up to date, the manager reported they would seek advice from the provider or the compliance lead within the home. We signposted the manager to Skills for Care and local registered manager support groups to ensure they had access to a safe, supportive space to connect with peers, share challenges, and build a strong collective identity within their local area.

The provider did not always work well across teams and services to support people. The provider was not always proactive in working with other services when multidisciplinary involvement was required and where people received care from a range of different services, there was limited documentation recorded to evidence this partnership working and how people’s care had been amended. The service had links with the local GP practice and district nursing team who visited the home.

People had mixed views about their care. One person told us, “I might need to see the optician as I can’t see very well, but no one [staff] have asked about this”. A second person said, “I’ve been asking [staff] to see a doctor for 2 weeks, but they haven’t arranged anything for me”. A third person told us, “I need to see a dentist, not needed the doctor but I’m sure [name of deputy manager] would get me one if I needed them”.

There was a lack of leadership and modelling of expected practice. Systems in place to record and monitor accidents and incidents were not being used effectively. The service did not ensure essential information about people’s care was available as information was not kept up to date or reflective of people’s needs. Care planning documentation was not updated following incidents to mitigate risk, and information within assessments was not always accurate, which could impact when people moved between services.

The service did not have a formal handover document in place to ensure important information and updates were relayed to staff on each shift. The manager informed us this information would be added to the service’s electronic care records system or messaged through the staff WhatsApp group. Some staff felt this level of communication worked well, whereas others felt it did not always work if staff been on leave.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control.

People were not always supported to be as physically active as possible to retain their mobility. We observed people sat for long periods of time and some staff were task focussed. One person was overheard saying they were bored, another told us they wanted to get outside more but couldn’t be due to lack of staff availability.

The new deputy manager had recently started setting up more structured or meaningful activities aimed at supporting mobility, rehabilitation, and cognitive stimulation. Most people were sat within the communal lounge or within their bedrooms. At the time of the inspection there was no activity co-ordinator in place, and staff took it in turns to provide activities for people. On our final day on site, people told us the quality and number of activities available had increased but they would still like more variety of physical activities to help them remain mobile.

Care plans did not always hold sufficient information to enable staff to have appropriate knowledge on any underlying health conditions of people. This would help staff to understand how to prevent and monitor for deterioration in their conditions.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We were not assured the provider effectively monitored people’s health conditions. There was no evidence people’s views were considered as part of these reviews. The manager told us they were planning to engage people and their representatives to review care plans and the menu on offer.

There were ineffective systems in place to monitor people’s care and treatment as there were limited audits in place to pro-actively identify issues, therefore the service was unable to continuously improve people’s care and treatment.

Care planning audits were not thorough, feedback was not collected, there were no care note audits, or observations carried out. The manager told the inspection team they carried out monthly checks of care records but could not provide documented evidence of which care records had been reviewed on each date and what action had been taken to update the records.

Falls, accidents, and incidents were not well managed. Records contained conflicting information regarding the frequency of incidents, what action staff took to safely help the person, as well as what action was taken in order to improve people’s outcomes.

There was limited guidance in place, or documentation to monitor and improve outcomes, people were not asked for their feedback. People told us they were not sure who the manager was.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The provider failed to ensure the correct procedure was followed in relation to the Mental Capacity Act 2005 (MCA). On reviewing people’s care records, we found examples where the provider had failed to ensure they acted in accordance with the legal requirements. For example, mental capacity assessments had not always been carried out when specific decisions needed to be made.

We found that for some people who had restrictive measures in place, such as sensor mats, decisions to review these were either overdue or were not completed to ascertain who was involved in the decision making, and if it was the least restrictive option. This indicated a lack of knowledge in relation to the Mental Capacity Act 2005 (MCA). Out of 18 staff, 14 had received MCA training and 13 had received equality and diversity training.

People told us staff usually respected their privacy and would ask for consent prior to supporting people with any activities of daily living. Staff provided good examples of how they would gain people's consent.

CCTV (closed circuit television) was in use in the communal corridors, kitchen, manager’s office and medicines room, however, there was no reference to this in people’s care plans to ensure people were aware of its use and had agreed to this. The manager told us people were verbally informed of having CCTV on the premises, and they also had a policy in place regarding the purpose of the CCTV. There was no documented evidence people, and staff had been involved in the decision to implement CCTV, and no evidence people and staff had consented to its use.