Bush Rest Home

Bush Rest Home is a residential care home providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 44 people.

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

Some care records required further detail about actions staff should take to keep people safe and to ensure compliance with the Mental Capacity Act. This was being acted upon by the registered manager. People felt the management team were approachable and that the service was well led. People had the opportunity to feedback on their experience of their care.

At the last 3 inspections we found shortfalls in the management of the delivery of care. This included a lack of understanding of risk and regulatory requirements, and care/risk plans without details of how staff should mitigate risks. At this inspection we found not all risks to safety had been assessed, however, staff knew how to reduce risks for people.

There were enough staff to meet people’s needs and people had received their medicines as required. There were infection prevention systems in place to reduce risks associated with infection..

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 supported by staff who understood their dietary needs and ensured these were met. People had access to healthcare support where needed. Staff received training relevant to their role.

People felt staff were kind and caring to them. People were treated with dignity and were encouraged to maintain their independence where possible.

People were supported by staff who knew them well. Records held about people gave personalised information about their preferences with regards to their care.

People were supported to keep hobbies that were important to them. Where complaints were made, these had been investigated.

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(published 06 October 2021).

Why we inspected

We received concerns in relation to the management of medicines and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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

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

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

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.

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.

When people tested positive staff were allocated to specific people and areas. Staff members regularly spent time interacting with people and doing activities during their isolation to promote people’s wellbeing.

Staff supported people to communicate with family through visits as well as phone and video calls. People also used video calls to communicate with each other when they were isolating in their own rooms.

Staff had completed Personal Protective Equipment (PPE) training and the provider had posters displayed in key areas to remind staff of the order to don and doff their PPE. Staff wore masks in the home and were observed doffing and donning PPE appropriately.

The provider had a clear testing regime in place for people and staff in line with current government guidance. Service users were monitored daily for signs and symptoms of COVID-19 to minimize the spread of infection.

Bush Rest Home is a residential care home providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 44 people.

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

Some care records required further detail about actions staff should take to keep people safe and to ensure compliance with the Mental Capacity Act. This was being acted upon by the registered manager. People felt that the management team were approachable and that the service was well led. People had opportunity to feedback on their experience of their care.

People were supported by staff who knew how to report any concerns of abuse to keep people safe. Risks to safety had been assessed and staff knew how to reduce risks for people. There were enough staff to meet people’s needs and people had received their medicines as required. There were infection prevention systems in place to reduce risks associated with COVID-19.

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 supported by staff who understood their dietary needs and ensured these were met. People had access to healthcare support where needed. Staff received training relevant to their role.

People felt that staff were kind and caring to them. People were treated with dignity and were encouraged to maintain their independence where possible.

People were supported by staff who knew people well. Records held about people gave personalised information about their preferences with regards to their care. People were supported to keep hobbies that were important to them. Where complaints were made, these had been investigated.

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 requires improvement (published 08 February 2020).

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.

Follow up

We will continue to monitor information we receive about the service until we 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:

People received person centred care and support based on their individual needs and preferences. Staff were aware of people's life histories and individual preferences. They used this information to develop positive, meaningful relationships with people. Staff were very knowledgeable about people’s changing needs and people and their relatives confirmed that changing needs were addressed. Staff who worked in the kitchen had a lack of understanding around people needs in relation to soft diets and diabetes.

People were supported by staff that were caring, compassionate and treated them with dignity and respect. Any concerns or worries were listened and responded to and used as opportunities to improve.

People told us they felt well cared for by staff who treated them with respect and dignity and encouraged them to maintain relationships and keep their independence for as long as possible.

People were supported by staff who had the skills and knowledge to meet their needs. Staff understood and felt confident in their role. People told us the atmosphere at the home was relaxed and friendly. Staff liaised with other health care professionals to ensure people's safety and meet their health needs.

Where people lacked capacity, 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.

Staff spoke positively about working for the provider. They felt well supported and that they could talk to management at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.

Audits were completed by management to check the quality and safety of the service.

Management worked well to lead the staff team in their roles and ensure people received a good service.

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 requires improvement (published 11 January 2019).

Why we inspected: This was a planned comprehensive inspection based on the rating of requires improvement at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

At this inspection we looked to see if sufficient improvement had been made to how people were being supported and the service was managed. We found improvements had been made and they were sufficient in some areas to remove the breaches in regulation 12 and 9. However the breach in regulation 17 remained with an overall rating of ‘Requires Improvement’ as the provider needed to show consistent improvement over a sustained period of time.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Bush Rest Home is registered to provide accommodation and support for up to 44 people who have conditions related to old age and/or dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. On the day of our inspection there were 34 people living at the home. There was no registered manager in post, however a manager had recently been appointed and would be applying to CQC to be the 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.

The provider needed to improve people’s care records so the support people received would be clear and not leave staff confused as to what support they needed. They also needed to ensure the new computer based records systems worked sufficiently to ensure the information kept was accurate and up to date.

Quality assurance processes needed further development to identify areas of concern. Although people could complete questionnaires the analysis was not shared with them so they would know what improvements would take place within the service.

While staff supporting people could access training so they had the right skills and knowledge, domestic staff required further training to ensure they had the right skills and knowledge to carry out their role. The provider followed the requirements of the Mental Capacity Act (2005), so people’s human rights were not restricted where they lacked capacity. People had access to health care professionals as required.

Staff showed people kindness and compassion in the way they supported them. People made their own decisions as to how they were supported. Staff respected people’s privacy, dignity and independence.

While people could raise complaints, the provider did not ensure a robust system was in place to show how complaints were logged and handled for future reference. People were not always involved in the process of reviewing the support they received. People could take part in activities they wanted as part of their assessed need.

People were supported safely as staff knew how to keep them safe. There was enough staff to support people on time and people received their medicines as it was prescribed. Staff knew how to ensure people were supported safely to reduce the risk of cross infection.

At our last inspection in November 2017 we identified significant improvements were needed throughout the service. We judged the home as ‘Inadequate’ in four of our key questions and identified seven breaches of the Health and Social Care Act 2008 and was failing to meet the requirements of regulations 12, 18, 14, 9,16, 20A and 17.

Following on from this inspection we placed the home in special measures and met with the provider and asked them to complete an action plan to show us what they would do and when by to improve all the key question(s) to at least “good.” Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

At this most recent inspection we found the provider had made some improvements and was no longer in breach of regulation 18,14,16 and 20A but in other areas improvements were still required. The overall rating for the service was changed to ‘Requires Improvement’. However, the service remains in ‘special measures’ as the provider could not evidence sustainability of the changes implemented and was also in continuing breach of regulations 12, 9 and 17.

Since our last inspection the registered manager has left the home and the home is being managed by a new manager who has not yet registered with the Care Quality Commission to manage the service. This means the home does not currently have a 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 told us they felt safe living at the home and staff could explain the actions they would take to keep people safe from abuse. Where people had specific risks in relation to their health or well-being, staff did not always manage these risks consistently to keep people safe from harm. Medicines were not always managed safely to ensure people received their medicines as prescribed. There were sufficient numbers of staff to meet people’s needs and they were recruited safely. Effective systems had not been fully established to learn from incidents, accidents or events that occurred to reduce the risk of re-occurrence. The home environment was clean and tidy.

Not all staff had the skills and knowledge to meet people’s care and support needs. Systems were not in place to ensure staff were competent in their role. Adequate systems had not been established to monitor and manage people’s nutrition and hydration needs. Staff lacked knowledge about which people were subject to a Deprivation of Liberty Safeguards [DoLS] and the application of DoLS by the provider was not effectively maintained.

Although some staff were seen to be engaging positively with people not everyone felt staff were caring. Staff sometimes missed the opportunity to engage with people as they were focussed on tasks. People were supported to make their own decisions about their daily lives and were encouraged to be as independent as possible. People were not always treated with dignity and respect.

People had access to some activities but there was little evidence of people being able to follow their individual interests. Care records were not reflective of people’s needs. People knew how to raise concerns or complaints and the provider had a system in place to investigate concerns.

The provider had failed to implement adequate systems to ensure the quality of service provided to people was sufficient to protect their health, safety and well-being. People and staff were positive about the new manager and said they were open and approachable. Although the new manager had not yet registered with CQC they understood the responsibilities of a ‘registered manager’ and the requirement to report certain incidents and events to us that had occurred at the home or affected people who used the service.

During this inspection we identified seven breaches of the Health and Social Care Act 2008 relating to safe care and treatment, staffing, person centred care, complaints, good governance, and failure to display. You can see what action we told the provider to take at the back of the full version of the report.

Bush Rest Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. There was a registered manager at the time of our inspection. 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.

Although people told us they felt safe, they were not always protected from the risk of harm because they did not always get their medicines as prescribed. We saw risks to people’s health and safety were not always managed in a safe way because staff used unsafe techniques to move people. When people were at risk of weight loss, guidance in place for staff had not been followed and some people had sustained further weight loss. When people sustained falls no investigations had taken place or learning from the accidents to ensure people’s risk of falling was minimised. The recruitment system operated by the provider needed to be improved to ensure staff were suitable to work with the people who lived at Bush Rest Home. Staff knew how to protect people from the risk of potential abuse. People told us and we saw there were sufficient staff to keep people safe. People were protected by the potential risks of infection as the home was clean and tidy.

Staff had received some training but it was ineffective as staff were not providing people with safe or effective care and systems were not in place to ensure staff were competent in their role. Peoples current needs were not always reflected in their care records. People had mixed views about the food. People’s nutritional needs were not always being met. People did not always receive co-ordinated care from health professionals. The design of the building was not always suitable for people living with a dementia. The principles of The Mental Capacity Act were not embedded in the care people received as people who had capacity to make their own decisions were not always involved in the decisions about their care. Staff were unaware of the people who had restrictions on their freedom at Bush Rest Home.

People told us and we saw staff were kind and caring but the systems the provider had in place did not always ensure people received compassionate and safe care. People were not always involved with their care. We saw people did not always have choices about their care. Staff did not always respect people’s privacy and dignity.

The care people received was not always responsive to their own individual needs. People told us they were bored because they did not have access to activities and no choices in how they would like to spend their time. People told us they had not needed to complain but if they did they would not know how to. The complaints system operated by the provider was not accessible to people who used the service or their relatives. There was a system in place should people reach the end of their lives to ensure they were pain free.

People were not supported by a management team who ensured the care they were receiving was safe. The service did not have systems in place to ensure the care people received was safe, effective, compassionate, and responsive to their own individual needs which meant people had received unsafe care. People had mixed views about whether the service was well led. Staff told us the management team supported them. Improvements were required in the leadership of the service to ensure staff were motivated and had a clear vision as to where the service is heading.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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 registered manager was present during our inspection. They had only started work at the home two months before our inspection. 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 we spoke with told us that they felt safe living at the home and relatives we spoke with confirmed this. We found that staff knew how to recognise when people might be at risk of harm and were aware of the registered provider’s procedures for reporting any concerns.

At the time of our inspection there were adequate staffing levels to meet people’s individual needs. People were supported by staff who had received training and had been supported to obtain qualifications. This ensured that the care provided was safe and followed best practice guidelines. Recruitment checks were in place to ensure new staff were suitable to work with people who needed support.

Most people received their medicines as prescribed; however, medications that were needed by people ‘as required’ were given by staff who did not always have the information they would need to administer these safely and consistently.

People’s needs had been assessed and written in care plans, however these were not person centred and did not inform staff how to support people in the way they preferred. Measures had been put into place to ensure risks were managed, but these had not been regularly updated or amended when people’s needs changed.

People’s nutritional and dietary needs had been assessed and people were supported to eat sufficient amounts to maintain good health. People were not always supported to have enough fluids to drink to keep them comfortable and well hydrated. We recommend that advice about nutritious food and drinks for older people is sought. People were supported to have access to a wide range of health care professionals.

Staff we spoke with had some knowledge of the requirements of providing care that upholds people’s legal rights, but were unable to consistently tell us how they uphold the rights of people who did not have capacity to make their own choices. We saw that staff did not always ask people to consent to their care on day to day issues. The registered manager had plans to review people’s consent in respect of many areas within people’s care. Some necessary applications to apply for Deprivation of Liberty Safeguards (DoLS) to protect the rights of people had been submitted to the local supervisory body for authorisation.

People told us that they were happy living at the home. We saw that staff treated people with respect and communicated well with people. People told us they wanted to go out more in their local communities. Some people were not offered the choice of social activities and had very limited access to activities within the home itself. People did not always have their dignity upheld.

There was a complaints procedure in place, and people told us they knew who to speak to if they had any concerns. Relatives told us they knew how to raise any complaints and were confident that they would be addressed.

We found there were ineffective systems in place to monitor and improve the quality of the service provided. The systems that were in place had not been effective in ensuring the home was consistently well led and compliant with the regulations. These were being improved by the registered manager.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. We spoke with four members of staff, three people who lived there and three relatives of people.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available on call in case of emergencies. One person told us "I am settling in well and I get a great night's sleep here."

Staff records demonstrated that mandatory training was up to date and that staff were trained sufficiently to meet the needs of people who lived there.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care that was delivered and that their needs were being met. It was clear from our observations and from speaking with staff that they had a good understanding of the people's care and support needs and they knew them well. People were cared for by staff who were supported to deliver care safely and to an appropriate standard. Staff had received training to meet the needs of the people living at the home and were supported to gain additional qualifications. The manager welcomed young apprentices to the service which acted as a bridge between people and local education providers.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. One person told us "Staff are calm and reassuring. Sometimes I get anxious but they explain things clearly and reassure me."

Is the service responsive?

People's needs had been assessed before they moved into the home. Records confirmed people's preferences and interests and personal histories were used to help staff understand each person's personality and emotional state. People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff had a good understanding of the ethos of the home and robust quality assurance processes were in place. People told us they were asked for their feedback on the service they received and a relative told us "The manager has an open-door policy, we can always approach them and they will welcome us." People told us that the food was very good and that they were always listened to when making a special request. Staff told us that they were clear about their roles and responsibilities and that management support was excellent. They said that they were supported to provide safe and effective care.

On the day of the inspection we spoke with the registered manager, three staff members, five people who lived at the home and five visiting relatives.

During the inspection we checked to see how people were involved and participated in the service they received. We found that people completed regular surveys to give feedback about the standard of service they received and participated in their care reviews where possible.

We found that people's care and welfare needs were being met by the home.

We saw that measures were in place to ensure people's safety in the home. We found that all staff had completed safeguarding training and staff we spoke with understood their responsibility to report safeguarding concerns.

We found that appropriate recruitment processes and checks were undertaken before people began working at the home. We saw that people were cared for by appropriately trained and suitably qualified staff.

We found that the provider had an effective system in place to deal with complaints.

One person living at the home told us, 'It feels like home here. The staff talk my language. I am very happy'.

One relative told us, 'This is a homely place. Staff have always got time for you. Our relative is in the best place possible. He says this home is his family'.