Breagha House

Breagha House is a residential care home which provides accommodation and personal care for young adults whom are living with a learning disability and/or autism. The service can support up to eight people. At the time of our inspection, five people were living there.

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

There were not always enough staff to give people the support they were assessed as needing. The management team confirmed recruitment was an issue for the provider, and they were continuously trying to find ways to remedy this. We identified that the record keeping in relation to training and induction for agency staff was not consistently robust.

People were protected from the risk of abuse. People’s needs were assessed, and any risks associated with their health conditions documented. Relatives felt their family members received safe care and support generally. People received their prescribed medicines safely. Risks associated with the service environment were now assessed and mitigated. The service was clean, and risks to people associated with acquired infections were minimised. Accidents and incidents were monitored to identify trends and prevent the risk of them happening again.

People's needs and choices were assessed in line with current legislation and guidance in a way that helped to prevent discrimination. The provider and manager had worked with the staff team to ensure they were up to date with the training and skills needed to support people. 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 and encouraged to have a varied diet that gave them enough to eat and drink. People were supported by staff to access healthcare services when required. The provider ensured the environment was suitable for people's needs.

The leadership of the service had improved since our last inspection. Relatives felt confident in the manager’s skills and ability to create a safe environment with good quality care for people. Staff we spoke with clearly understood their roles and responsibilities and felt able to make suggestions to improve people’s daily lives.

The provider and manager had implemented systems that helped them to analyse the causes of incidents or poor care and identify risks to people. This information was then used to improve the quality of care. The provider was working with the local authority and CQC in an open and transparent way to ensure the quality of the service steadily improved. Local authority staff involved in safeguarding processes for people felt the service was much improved since our last inspection.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of Safe, Effective and Well-led the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

People were able to have choice and control in their day to day decisions. Staff were supported to demonstrate the values the provider felt essential to delivering good quality care that was person-centred. The provider and manager were dedicated to ensuring staff demonstrated values in line with Right support, right care and right culture. The provider was looking at ways to develop staff knowledge and skills which meant people were being supported in the best way possible. This was through reviewing peoples’ care, enhancing staff knowledge and training and listening to people and their relatives.

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 3 August 2021) and there were multiple breaches of regulation. At this inspection we found improvements had been made. The provider was still in breach of Regulation 18 (Staffing) but was no longer in breach of any other regulations.

This service has been in Special Measures since 2 August 2021. During this inspection the provider demonstrated that 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 inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

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 monitor the service.

We have identified a breach in relation to regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this inspection. Please see the action we have told the provider to take at the end of this report.

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.

Breagha House is a residential care home which provides accommodation and personal care for young adults whom are living with a learning disability and/or autism. The service can support up to ten people. At the time of our inspection, ten people were living there.

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

People were not kept safe from the risk of abuse. Staff did not always feel confident to raise concerns or did not feel their concerns would be taken seriously. People were at risk from neglectful and abusive care practices.

Risks to people's health, safety and welfare had not been adequately assessed and mitigated. The provider had not ensured people lived in a safe environment. There were not enough staff to keep people safe. People’s medicines were not managed safely.

We were not assured that the provider had good infection control practices. The provider did not learn lessons when things went wrong.

People's needs and choices were not assessed in line with current legislation and guidance, or in ways that helped to prevent discrimination. People were not supported to communicate in ways which were meaningful to them.

People were at risk of receiving support from staff who were not trained to meet their needs. People were at risk of being offered unhealthy and unsuitable food choices, and at risk of not being able to participate in their own meal planning.

People were not always supported to access external health appointments in a timely way. Consent to care was not sought in line with legal requirements.

The service was not well-led. People were put at risk because the provider and registered manager failed to ensure suitable quality assurance checks were in place. The provider did not ensure staff followed policies and procedures for the delivery of safe care.

The provider had not consistently notified CQC of significant events as they are legally required to do. Systems and processes to assess risk and monitor quality were insufficient and ineffective in driving improvements.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People’s care was not person-centred and did not promote their dignity and rights. Due to the range of safeguarding concerns being investigated by the local authority and police, we felt there was a risk some staff did not demonstrate attitudes and values that promoted compassionate and inclusive care.

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 14 September 2019).

Why we inspected

We received concerns in relation to staffing levels, medicines management, safeguarding issues, restrictive care practices, and poor management practices. As a result, we undertook a focused inspection to review the key questions of Safe, Effective and Well-led only.

The inspection was also prompted in part by notification of a specific incident, following which a person using the service sustained a serious injury. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

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.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

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

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 regulations 9, 11, 12, 13, 14, 15, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

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 have already met with the provider 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.

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.

Breagha House is a residential care home, providing personal care for 10 people aged 18 and over at the time of the inspection. The service can support up to 10 younger adults who have a learning disability or autistic spectrum disorder. Accommodation was provided in a purpose built home across two floors, with communal areas on each floor.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to ten people. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras outside to indicate it was a care home, although industrial bins were visible from the road. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

Although there was a clear management structure and communication strategies in place at the service, the quality monitoring processes in place did not always highlight when documentation around incidents and restraint had not been completed thoroughly. This presented a risk that people would not be cared for in a consistent way.

People were protected from abuse, as staff were aware of their role in safeguarding people and the provider worked closely with the local authority teams to manage any safeguarding issues. At the time of our inspection there was one safeguarding investigation open, and the local authority told us the service had worked with them in an open and transparent way.

The risks to people’s safety were assessed and managed safely using evidence-based assessment tools, however there were some recording issues in people’s records which the registered manager told us they would address. Following our inspection, we received information from them to show this had been addressed.

People were supported by a group of staff who had been provided with effective training for their role. The numbers of staff reflected and met the needs of people at the service. There were safe recruitment processes in place.

People lived in an environment which was clean, well maintained and provided them with space and privacy. There were effective infection control processes in place to protect people from the risks of infection.

People’s nutritional and health needs were well managed. They 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 received person centred care from a group of staff who knew their needs very well. There was a caring attitude towards people from the staff who supported them. We saw a number of positive interactions between staff and people at the service. One relative told us staff had been “Amazing and very supportive” to both them and their family member. Staff worked to maintain people’s privacy, dignity and encourage their independence.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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 19 September 2017)

Why we inspected

The inspection was prompted in part due to concerns received about physical intervention and staff practice in the service. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern. The provider had taken immediate steps in response to the concerns and was co-operating with the relevant authorities in the investigation to keep people safe from the risk of these concerns. Please see the Safe section of this full report.

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. People were involved with the menu choices and had access to drinks and snacks.

The approach of staff was caring, kind and sensitive. Staff respected people’s privacy and dignity and used good communication skills, people were relaxed within the company of staff. People who experienced periods of anxiety were supported appropriately, staff were calm and responsive.

Opportunities for people to be involved in their care and support had improved. Weekly meetings had been introduced to support people in menu planning. Staff engaged positively with people, constantly offering them choices and respecting and acting upon these. Independence was positively promoted at every opportunity. Independent advocacy information was available if this support was required.

Opportunities for more meaningful activities and opportunities had improved and were being further developed. People had individual activity planners that gave a structure of how they spent their time, but this was flexible and dependent on people’s needs and choices on the day.

Information to support staff to understand people’s needs, routines, interests and hobbies had improved. New documents had been introduced to record and celebrate people’s achievements, and action was taking place to support people to develop person centred plans that identified their goals and aspirations. Information about the provider’s complaint process was available and presented appropriately to meet people’s communication needs.

Relatives had been invited to give feedback about the service, and there was increased communication with relatives who were positive about the improvements that had been made at the service.

Significant improvements had been made to the governance of the service. Audit systems and processes responsible for monitoring quality and safety had been reviewed and more robust procedures had been implemented. There was greater oversight of the service by the provider’s representatives and increased scrutiny and accountability of senior managers. The provider was meeting their regulatory requirements.

We were informed prior to our visit that the registered manager was no longer 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.

Action was not always taken to reduce the risk of people being placed at risk of abuse. Risks in relation to people’s daily lives were not always assessed and planned for to protect them from harm and people were being placed at risk of harm.

People did not always receive appropriate care and support as there were not enough staff deployed in the service. Medicines were not always managed safely.

People were not protected from avoidable restraint and were supported by staff who did not have all of the knowledge and skills they needed to provide safe and appropriate care and support.

People were supported to make some decisions and staff knew how to act if people did not have the capacity to make decisions. However staff did not always act in people’s best interests.

People were not fully supported to maintain their nutrition. People were supported to attend health appointments.

People were supported by staff who knew them well and sometimes cared for them with compassion but staff were not empowered to support them in a way they would prefer. People were not always given the opportunity to live their life to their full potential or enjoy an active social life.

The systems in place to monitor the service had been ineffective in maintaining the quality of the service people received. This had led to deterioration in the quality of the service and people being placed at risk of harm. The lack of appropriate governance and risk management framework had resulted in us finding multiple breaches in regulation and this had led to people being placed at risk of harm and receiving care and support that was not safe.

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.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The service had a registered manager in place 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.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. Risks in relation to people’s daily life were assessed and planned for to protect them from harm.

People were supported by enough staff to ensure they received care and support when they needed it. Medicines were managed safely and people received their medicines as prescribed.

People were supported by staff who had the knowledge and skills to provide safe and appropriate care and support. People were supported to make decisions and staff knew how to act if people did not have the capacity to make decisions.

People were supported to maintain their nutrition and staff were monitoring and responding to people’s health conditions.

People lived in a service where staff listened to them. People’s needs were recognised and responded to by a staff team who cared about the individual they were supporting. People were supported to enjoy a social life.

There were systems in place to monitor and improve the quality of the service but these were not always effective in making improvements to record keeping. People lived in an open and inclusive environment and were involved in giving their views on how the service was run.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with two people who lived at the service, three relatives, two care workers and the registered manager. We also looked at some of the records held in the service including the care files for two people. We observed the support people who used the service received from staff and carried out a brief tour of the building.

We found people gave consent to their care where possible and the provider acted in people's best interests when needed. The care and support people received met their needs.

Staff were provided with the leadership they required to protect the rights of people who did not have the capacity to consent. There were sufficient numbers of suitably trained and experienced staff to meet people's needs and the provider maintained records that were accurate and fit for purpose.

We found the staff team were supported through training, and the records in use protected people from the risk of unsafe or inappropriate care and support.