Brunel House

Brunel House is a care home providing nursing and personal care to 40 people aged 65 and over at the time of the inspection. The service can support up to 65 people. People live on three floors of the building, one of which specialises in providing care to people living with dementia.

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

The provider did not always ensure there were enough staff working in the home to meet people’s assessed needs. People, their relatives, staff and visiting professionals told us there were not enough staff working in the home at times. The lack of staff impacted on people’s ability to receive care in a timely way. Staff felt they were rushing when providing care for people and were not able to provide person-centred care.

Risks to people were not always effectively assessed and managed. Action was not consistently taken following incidents to reduce the risk of a similar incident happening again.

The provider did not have effective systems in place to assess the quality of the service provided and make improvements where needed. The management team had not completed some of the regular checks and audits that were needed for effective oversight of the service. The systems had not identified some of the shortfalls we found during the inspection.

We made a recommendation that the provider reviews the medicines management practice, to ensure their procedures are followed consistently. There was not always an accurate record of medicines held in the service and one person regularly received time-specific medicine either early or late.

The home had good infection prevention and control procedures in place. Procedures had been reviewed and updated to reflect the COVID-19 pandemic. Systems were in place to prevent visitors catching and spreading infections.

The regional director had identified the need for improvement in the service and had brought in a ‘service support team’. These were additional staff tasked with identifying and implementing improvements to the service.

Staff demonstrated a good understanding of people’s individual needs and a commitment to provide person-centred care. However, they were frustrated at the staffing circumstances which made this difficult.

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 10 January 2020) and there was a breach of regulations. The provider completed an action plan after the last comprehensive inspection to show what they would do and by when to improve. We completed a targeted inspection in February 2021 and the provider had made the improvements necessary. At this inspection we found the service had deteriorated and there were further breaches of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about staffing and management of the service. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvement. Please see the safe and 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.

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.

Brunel House is a care home, which provides personal and nursing care to up to 65 people. The home also supports people living with dementia.

The home is arranged over three floors. There are single bedrooms with en-suite facilities, and communal areas on each floor. There is a passenger lift to give easy access, and a well-maintained garden.

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

Improvements had been made to the safe administration of medicines. Medicines people chose to take had been appropriately ordered from the pharmacy, so were available when needed. Staff had completed the medicine administration records correctly, to show people had taken their medicines as prescribed. There was a discrepancy however with the instruction of one medicine. This was quickly addressed once brought to the attention of the registered manager. How a person liked to take their medicines was detailed in their care plan. Detailed guidance was generally available to enable ‘as required’ medicines, to be given with maximum effectiveness. Any guidance, which was not in place was addressed immediately after the inspection. Staff had received training in the safe management of medicines and their competency had been assessed.

Robust infection prevention and control policies and procedures were in place and adhered to by staff. The information was based on national guidance. Staff had received additional training in infection prevention and control. They had the required personal protective clothing and wore it correctly. Staff changed into their uniforms on site to minimise the risk of transmission. Staff were monitored and audits took place, to ensure procedures were being appropriately followed.

There had been an outbreak of COVID-19 in the service. This had been appropriately reported to the required agencies. Additional guidance was sought and implemented, to minimise the risk of transmission throughout the home. Those staff who had the virus self-isolated, and only returned to work when well. Staff and people who had consented, have undertaken regular testing for COVID-19.

The home was clean with no unpleasant odours. Some windows, which did not impact on people, were open to help ventilation. There were stringent cleaning schedules, which included additional cleaning of high touch areas. The environment had been adapted to enable social distancing. Some armchairs and dining room chairs had been replaced to ensure they could be easily wiped.

Staff supported people to keep in touch with their friends and relatives. Strict visiting procedures, in line with national guidance, were in place to ensure safety. Relatives told us they had confidence in the staff team and the measures to minimise infection. However, they said limited visiting, as directed by the government, was difficult and challenging. The registered manager and staff recognised this, so tried to keep families informed and updated as much as possible.

Rating at last inspection and update

The last rating for this service was requires improvement (published 11 January 2020) and there was one 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, enough improvement had been made and the provider was no longer in breach of regulations.

Why we inspected

The inspection was prompted due to the outbreak of COVID-19 in the home and to look at the breach of regulation, which was identified at the last inspection.

CQC have introduced targeted inspections to follow up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe section of this full report.

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

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.

Brunel House is arranged over three floors and offers a service for up to 65 people across three units which include nursing and dementia care.

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

We responded with an early morning visit due to concerns raised about staff getting people up too early. While four people were up when we visited, we found bedside lights and bedroom doors open on two floors. We spoke with the registered manager who investigated and gave us reassurances this practice was not usual.

Whilst the service had processes in place for the safe storage, administration and use of medicines, these were not always followed, in particular the ordering and stock control of medicines.

There was a large volume of waste medicines awaiting collection for disposal, indicating ineffective stock management.

Records showed that people did not always receive their medicines, due to stock not being available despite there being systems and process in place with the service, GP and community pharmacy.

Records also showed that people did not always receive their medicines as intended due to people sleeping, yet there was no evidence that there was a process in place for sleeping people to enable medicines to be offered once awake or where a persistent occurrence with an individual, a review to be undertaken with the prescriber to address this.

Individual risks were assessed and analysed. Where risks were identified there were preventative measures in place to reduce the risk. There were people who at times challenge the staff and placed themselves and others at risk of potential harm. Specific plans were not in place on how staff were to manage these situations. Incidents recorded in the behaviour charts (for direct observation used to collect information about the events of behaviours) were not analysed. We found descriptions of incidents recorded in behaviour charts were variable in quality of detail and the post incident consideration box was very rarely completed. There was little evidence that the behaviour charts were reviewed.

Despite the feedback from staff and relatives that staffing levels were not adequate, the registered manager said the staffing levels were above the dependency assessment of people’s needs. Relatives and staff said more staff were needed. We have made a recommendation about the review of staffing levels.

Recruitment processes ensured the staff employed were suitable to work with people at risk

People’s needs were assessed before their admission. Assessments included people’s preferences, relationships, hobbies and interests. Although care plans were more person centred, they were variable in quality and needed to improve to the same standard. We recommend that care plans are brought to the same upper standard.

People said they felt safe living at the home. Safeguarding processes and systems were in place. Staff were knowledgeable about the safeguarding of people at risk procedures.

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.

Accidents and incidents were recorded investigated and analysed.

New staff attended an induction when they started work at the home. There were systems in place to support staff with their performance, to develop their skills and there were opportunities for personal development.

People told us the food was good and relatives said the food had improve. People were supported with their ongoing healthcare needs.

We saw examples of kind and caring staff. Relatives spoke highly of the care staff delivered. Staff were knowledgeable about people’s preferences and how to build trust. Where people were receiving palliative care, their end of life care was pain free and dignified.

There were group activities which people who attended enjoyed. The recently appointed activities coordinator will develop one to one activities as this was not fully operational at the time of the inspection.

Relatives told us who they approached with complaints. Logs of complaints showed they were analysed and resolved.

The staff said the leadership qualities of the registered manager had improved the care delivery for people. The staff said the registered manager was "fantastic" but felt this registered manager was under pressure to meet targets. When we repeated the feedback from staff the registered manager disagreed with their comments that they were under pressure.

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 07 November 2018). 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 but the provider was still in breach of other regulation.

The service remains rated requires improvement. This service has been rated requires improvement for three consecutive inspections

Why we inspected

This was a planned inspection based on the previous rating.

The inspection was prompted in part due to concerns received about lack of staff at night. A decision was made for us carry out an early morning inspection to examine those risks.

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

This inspection took place on 26 of September 2018 and was unannounced. We returned on 27 September to complete the inspection. At the time of the inspection there were 58 people living at the home.

At the last inspection dated July 2017 we found breaches of fundamental standards in relation to Regulations 5, 9,10 11 and 12. The provider developed an action plan detailing how they would take steps to meet the requirements of the legislation and action plans were monitored by the provider. While we found that some improvements had been made these were insufficient in all areas.

This is the second consecutive time the service has been rated Requires Improvement

A registered manager was 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.

There was a programme of monthly audits included sample checks of care plans and medicine audits. We saw there were repeated issues in relation to medicines. Clinical audits were monthly and related to areas of risk such as pressure areas, weight and falls. Along with reports of commissioners visits we raised with the registered manager that reports of daily entries were not person centred. For example, staff documented reports of clinical support and direct care provided. The registered manager explained how this was to be addressed. However, records were not always up to date and accurate.

Risk management systems were used to assess people’s individual level of risk. Action plans were devised where risks were identified. However, risk assessments were not always updated to show where the risk had increased and monitoring checks were not consistently completed.

Care plans were not always person centred. Some care plans were inconsistent with the aim of the plan, the individual’s abilities and current needs. Some end of life care plans although included the priorities of care lacked person centred care. Daily notes were task focused and included direct care delivered. Where people used repetitive behaviours care plans were not always in place on how staff were to manage these behaviours.

There was an electronic system for medicine administration and audits of medicine systems showed there were persistent issues. The audit reports showed that staff were not signing when cream and lotions were applied. In the dementia unit we noted a number of people were prescribed with medicines for anxiety. The protocols were not person centred and did not give clear guidance on how people expressed anxiety.

The home was clean well decorated and free from unpleasant smells. We saw housekeeping staff on duty within the home.

The staff we spoke with knew the types of abuse and to report their concerns. They said they had attended safeguarding adults training to help them recognise the signs of abuse and about reporting concerns. People said they mostly felt safe living at the home. The registered manager told us the actions they will take to ensure people felt safe from those that made them feel at risk of harm.

We saw adequate number of staff available to support people with daily needs. People told us the staff responded to their request for support and assistance. They said if staff had time they took the time to have a chat. Relatives said occasionally staffing levels dropped especially at weekends. Some staff told us they felt rushed and expressed that better deployment of staff with equal skills was needed to be on duty.

Where possible people made decisions about their day to day care and relatives said they were consulted. Staff were knowledgeable about the principles of the Mental Capacity Act 2005. Capacity assessments were in place for accommodation, continuous supervision and complex decisions. Deprivation of Liberty Safeguards were applied for where appropriate.

Staff gave positive feedback about the training offered and attended mandatory training which the provider had set. One to one meetings with a line manager had taken place.

People had access to healthcare services as required and dietary requirements were catered for.

People we spoke with and relatives praised the staff for their caring manner. Without exception the people, relatives and professionals we spoke with said they would recommend the home.

We saw some good interactions between people and staff. Staff knew people’s preferences and how they wanted their care delivered.

The complaints procedure was on display. There was one complaint from a relative and a satisfactory outcome was reached.

There was continuous learning from accidents. Preventative action was taken to ensure people’s safety. For example, in the dementia unit lighting was improved to remove shadows which caused distress that resulted in falls to some people. Since then number of falls have reduced.

We made a breach of Regulation 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.

This inspection was over two days which took place on 19 April and 2 May 2017. The visit on the 19 April was unannounced and the manager was aware of the second visit on 2 May 2017.

Brunel House provides a service for up to 65 people. The staff provide care and treatment to people with nursing needs and to people living with dementia.

A registered manager was not in post. The current manager will be making an application to register with us. 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.

Risks were not managed appropriately. Risks assessments on how staff were to minimise risk were not always in place and staff had not recognised when people were at risk of harm. For example, risk assessments were not in place for people at risk of choking. Where risk assessments were in place they lacked detail on how staff were to minimise the risk. For example, how staff were to support people when they became anxious.

Waterlow assessments were completed by the staff to identify the potential of people developing pressure ulcers. Action plans were not developed on how to minimise the potential of skin breakdown. Body maps were used to locate the position of injures but reviews had not taken place to monitor the healing progress of the wounds.

Incidents and accidents were not always reported by the staff. We saw where people had sustained injuries managers were unaware of them having occurred. This meant accidents and incidents were not fully analysed to prevent any reoccurrence. The manager said where accidents and incidents were reported the quality assurance team shared learning from an analysis of trends and patterns.

Medicine systems needed improving. Protocols for when required medicines (PRN) were not in place for all PRN medicines and where they were in place they lacked detail. Protocols lacked detail on the signs which identified to staff that PRN medicines were needed. Care plans were not in place for the administration of covert (disguised) medicines. Guidance on the best method of disguising the medicine was not sought from the pharmacist.

Staff’s opinion on the quality of training was mixed. Some staff said the online training provided did not provide an opportunity for the staff team to share learning. Other staff said the quality of the training was poor for example, Mental Capacity Act 2005 (MCA) training and other staff said higher level of dementia training was needed for staff working on units where people were experiencing dementia .

The staff were knowledgeable about how to enable people to make day to day decisions such as menu choices, activities and what people would like to wear. We saw good examples of staff supporting people to make choices. However, staff lacked knowledge of the MCA and were not working within the principles of the act. Guidance from healthcare professionals was consistently disregarded for one person. MCA assessments were not undertaken to ensure where people had cognitive impairments they had the ability to understand the consequences of the decision taken.

People were not involved in the planning of their care. Care plans were inconsistent and lacked detail on how staff were to deliver care and treatment in people’s preferred manner. Care plans on how staff were to manage difficult behaviours when people living with dementia expressed their frustration in an aggressive manner were not clear and did not provide sufficient guidance to staff. While care plans were reviewed the care plans were not updated with people’s changing needs.

Moving and handling risk assessments were in place for people that needed assistance with moving around the home. Within the risk assessments were the equipment needed for each movement and the number of staff to assist the person with transfers.

Malnutrition Universal Screening Tool (MUST) were used to assess the potential of people developing malnutrition. Action plans were developed on how to support people to maintain their weight, for example, monitoring people’s food and fluid intake, serving fortified drinks and enriched meals.

There was a variety of opinions about staffing levels. Some staff said the staffing levels were appropriate while other said there were shortages of staff. Agency staff were used to maintain staffing levels for existing staff vacancies.

People told us they felt safe living at the home and the staff made them feel secure. Members of staff were knowledgeable about the safeguarding of vulnerable adults from abuse procedures. They were able to identify the types of abuse and expectations they report abuse.

People told us the staff were kind and caring. The staff understood the importance of developing relationships with people. We saw staff communicating with people in a way they understood. When people needed support from staff we observed a discreet approach being used to offer assistance.

Quality assurance systems that assess and monitor systems were in place. A programme of audits had taken place and a developmental plan introduced on the improvement needed. Visits on behalf of the provider were monthly to monitor that improvements were taking place. Action plans on the areas for improvements were in place and where actions were ongoing the timescale was amended.

You can see what action we told the provider to take at the back of the full version of the report.’

Appropriate checks were undertaken before staff began work. Recruitment was underway for nurses, a deputy manager and domestic staff. Staff had received training in key areas so that people were supported safely and protected from harm.

Senior managers visited the home regularly to monitor all aspects of the running of the home including the care people received, the records held, and staffing.

People and their family members were asked for their views about the quality of the service. We spoke with two relatives, and three staff. Comments made by relatives included 'a few staff go the extra mile' and gave examples of when some staff had supported their relative in a caring and kindly way. Other comments relating to people's care included 'very well looked after, they do well' and 'like a hotel, can't fault it at all'.