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We are carrying out a review of quality at Breagha House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 19 September 2017

We inspected Breagha House on 8 August 2017. The inspection was unannounced. Breagha House is a large, modern detached property in the village of Hayton, near Retford in Nottinghamshire. It is owned by Kisimul Group Limited. It is registered to provide care for up to ten younger adults with a learning disability. On the day of our inspection ten people were using the service.

The service had a registered manager in place at the time of our inspection. The registered manager registered with the Care Quality Commission on 6 June 2017. 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 our last inspection on 14 and 20 February 2017 we identified significant failings and multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safe care and treatment, safeguarding people from abuse and improper treatment, staffing, dignity and respect, person-centred care, good governance and not notifying the Care Quality Commission for incidents the provider was legally obliged to do. The provider sent us an action plan to tell us what action they would take to meet these breaches in regulation.

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.

Staff had received safeguarding refresher training and additional training to support them to manage safeguarding incidents more effectively. New processes and systems had been introduced as additional measures to monitor safety.

Risks associated to people’s individual needs including the environment, had been reassessed and care records updated to provide staff with the required information to protect people’s safety. These were regularly reviewed and amended to reflect people’s needs. Action had been taken to improve some aspects of the environment to ensure people’s safety.

Significant improvements had been made to the staffing levels; these were appropriate and supported people’s needs. Consideration had been given to the staff skill mix, ensuring a balance of skills, competencies and experience. New staff had completed all required recruitment checks before they commenced their employment.

Medicines were managed, stored and administered safely. Staff had the required information and had completed appropriate training. Monitoring checks were in place that assured the provider people received their prescribed medicines safely.

Improvements had been made to staff training and ongoing support. Staff received regular opportunities to refresh their skills and knowledge and to review their training and development needs.

Staff understood how to apply the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Mental capacity assessments and best interest decisions had been reviewed to ensure least restrictive options had been considered and applied. Staff had received specific training around managing behaviours that could be challenging. This had a positive impact on people and incident of physical intervention had significantly reduced.

People’s nutritional and health needs had been reviewed and staff had the required information to support people with these needs. Staff had worked with external healthcare professionals and had supported people to attend heath appointments as required. People’s health needs were monitored and recorded. Peopl

Inspection areas



Updated 19 September 2017

The service was safe.

Staff had received refresher safeguarding training and additional training to better understand and manage safeguarding incidents effectively.

Risks associated to people’s needs had been reassessed and staff had the required information to protect people.

Staffing levels were appropriate and new staff completed detailed recruitment checks before they started work.

People received their prescribed medicines safely.



Updated 19 September 2017

The service was effective.

People were supported by staff that received an appropriate induction and ongoing training and support.

People’s rights were protected by the use of the Mental Capacity Act 2005.

People received choices of what to eat and drink and menu options met people’s individual needs and preferences.

People received support with any associated healthcare need and staff had the required information to support them. Staff worked with healthcare professionals to support people appropriately.



Updated 19 September 2017

The service was caring.

People were supported by staff who were kind and caring, and knowledgeable about people’s individual needs.

People were supported to access to information about independent advocates of this support was required.

People’s privacy and dignity were respected by staff and independence was promoted.



Updated 19 September 2017

The service was responsive.

Activities and opportunities that reflected people’s interests and hobbies had increased. Action was being taken to support people with identifying their hopes, dreams and aspirations.

Opportunities for people to be involved in their support had improved.

Information about how to make a complaint was available in an appropriate format.



Updated 19 September 2017

The service was well-led.

Improvements had been made to the service and previous breaches in regulation had been met. A new registered manager and deputy manager had been appointed.

Significant changes had been made to improve the governance of the service; there was an increase in accountability and scrutiny. The provider’s representative’s had better oversight of the service.