Archived: Bramble Lodge Care Home

This service provides support and accommodation for up to 41 people who are assessed as requiring residential or nursing care. This includes support for people living with dementia and/or mental health conditions. At time of our inspection there were 19 people living at Bramble Lodge Care Home.

Bramble Lodge Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is a purpose built, detached building in a residential area of Middlesbrough. It is set out over two floors.

At our last inspection in January 2017 we found that there were continued gaps in records in all areas looked at. Audits had not highlighted any of the concerns which we found during inspection. Staff completed records for people when they had not been involved in their care and care records were not completed in a timely manner. A safeguarding alert for neglect had been upheld in respect of record keeping. We issued a warning notice for this breach of Regulation 17 (HSCA RA) Regulations 2014 in relation to Good governance. We asked the provider to make improvements in this area.

Whilst improvements had been made to quality assurance systems within the service, audits had not identified issues we found with staff training and the fire procedure. We have made a recommendation about provider audits.

We also found at the last inspection that people’s care records did not show if they were subject to a ‘Deprivation of Liberty Safeguard,’ (DoLS). Care plans did not contain any information about people’s capacity to consent or their level of understanding in each of their identified care needs. Staff displayed limited knowledge and understanding of DoLS and best interest decision making had not been carried out when needed. This was a breach of Regulation 11 in relation to the need for consent. We asked the provider to make improvements in this area and this action had been completed.

When we inspected the service, the manager was going through the process of becoming a registered manager having taken up their position in February 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered person’s'. 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.

We found during this inspection that the fire evacuation procedure was not clear. Information provided by staff was inconsistent and contradicted information on notices displayed throughout the building. The manager sent us information following the inspection showing that the fire procedure had been rewritten and that liaison with the fire brigade had taken place. They also provided us with the dates that staff would be trained in the new procedure.

Nursing staff had not always received training or refresher training to develop and maintain their clinical skills in areas such as catheter care. The manager had ensured that care staff were scheduled to have or had received training to be able to carry out their role, including training in areas the provider deemed as mandatory such as health and safety, safe food handling and falls prevention. However, there was no evidence that staff had received face to face people movement training, only an online version. This meant that their competency in this area may not have been thoroughly assessed. The manager sent us a plan following this inspection which set out how the training issues identified would be addressed.

People’s files contained the information staff needed to support them. General risk assessments were in place and regularly reviewed. Risks to individuals were also documented with information available for staff in how to manage these in order to reduce the risks to people.

We found that whilst medicines were administered appropriately the administration of medicines was not always recorded correctly.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The environment was clean and staff knew how to help control the spread of infection. Equipment checks were undertaken to help ensure the environment was safe. We did however identify that wardrobes had not been secured to walls creating a risk to people living with dementia. Emergency contingency plans were in place.

Policies and procedures were in place to support staff in protecting people from harm, such as safeguarding and whistleblowing polices. Staff knew how to identify and report suspected abuse. People and their relatives felt the service was safe.

There were sufficient numbers of care staff on duty to ensure people’s needs were met. Safe recruitment practices were in place. Pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with vulnerable people.

Staff said that they were supported through regular supervision and that they felt they could approach the management team if they had any issues.

People had access to a range of healthcare services such as GPs, hospital departments and dentists.

People’s nutritional needs were met and they enjoyed a diet that met their preferences. People told us they enjoyed the food.

The premises were spacious and tidy however some areas required updating to ensure they were suitable for people living with dementia.

People were supported by a regular team of staff who were knowledgeable about their likes, dislikes and preferences. Visitors told us that they were made welcome.

Staff members were kind and caring towards people. People’s privacy, dignity and independence were respected. The policies and practices of the service helped to ensure that everyone was treated equally. Care plans included information about people as individuals including their preferences. End of life care procedures were in place.

Staff encouraged people to access a range of activities and to maintain personal relationships.

Meetings for staff took place regularly. Meetings for relatives and people living at the service were not well attended. The manager was considering how this could be improved.

The service worked with a range of health and social care professionals to ensure individual’s needs were being met. Feedback was sought to monitor and improve the service.

Staff were positive about the management team. They confirmed they could raise concerns. Learning took place following reviews of accidents and incidents where themes and trends were addressed. A clear complaints policy and procedure process was in place.

This is the fourth consecutive time the service has been rated Requires Improvement.

We carried out a comprehensive inspection of the service on 09 September, 12 October, 13 October and 22 December 2015 and found that the service was not meeting all of the regulations which we inspected. We identified a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because there were gaps in the information contained in care plans. There was inconsistency between care plans. Regular reviews of risk assessments and care plans had not been carried out. Records relating to the care and support people received each day which included their nutrition and hydration had not been kept up to date.

At inspection in January 2015 we found that the service was not accurately and effectively maintaining records. This meant there was a breach of regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was identified because care plans lacked the detail needed to show that person centred planning was being used to support people in all aspects of their life. People’s involvement in their care was not accurately documented and reviews of care did not evidence how care, support and intervention was reducing and enabling people to live to their full potential.

At this inspection, we identified a continued breach of records. We could see improvements had been made in some areas; however this was not in all of the areas expected. We found gaps in record keeping included topical cream records, dates of opening on topical creams and eye drops and fridge and room temperatures. Repositioning charts had not been fully completed and we found scores on nutritional screening tools were inaccurate. Health and well-being records, which included food and fluid balance information was not completed in a timely manner and were completed by staff who had not been involved in people’s care. There were gaps in care plans and in the frequency of reviews. A safeguarding alert for neglect had been upheld for record keeping. This meant staff had not obtained all of the information they needed when a person started using the service. The registered manager had acted following this and had made changes to pre-admission records to reduce any future risk of harm caused by poor record keeping.

There were gaps in quality assurance processes. Audits had been carried out at the service by the registered manager and registered provider; however they had not highlighted all of the concerns which we had during this inspection.

Some people using the service had been deprived of their liberty to receive care and treatment. This meant people were subject to a 'Deprivation of liberty safeguard,' (DoLS). We could see these applications had been carried out in people's best interests and staff had followed the legal framework of the Mental Capacity Act 2005. However, people's care records did not contain any information to show if they were subject to DoLS, their capacity to consent or their level of understanding in each of their identified care needs. We found that staff displayed limited knowledge and understanding of DoLS and best interest decision making had not been carried in relation to a 'Do not attempt cardio-pulmonary resuscitation' certificate and an influenza vaccination.

Risk assessments were in place for people; however they had not always been reviewed within four weekly intervals as stated on the records. Some risk assessments were inaccurate because they had been calculated incorrectly.

This service provides support and accommodation for up to 41 people who are assessed as requiring residential or nursing care. This includes support for people living with Dementia and or mental health condition. At the time of inspection there were 36 people using the service. Bramble lodge care home is located in a residential area close to local amenities within its own grounds and has on-site parking.

The registered manager had been registered with the Commission since 6 December 2010. 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.

Staff understood the procedures they needed to follow if they suspected abuse could be taking place. Staff discussed potential signs and symptoms which people could display if abuse was taking place.

Personal emergency evacuation records were in place. These were available in the central office and on the backs of people’s doors which made them accessible during an emergency.

People and staff told us there was enough staff on duty during the day and night. We observed staff carrying out their roles and sitting with people throughout both days of inspection.

People told us they received their medicines when they needed them. However improvements were needed to topical creams and eye drops because they did not contain dates of opening.

All staff were required to undertake mandatory training, as specified by the registered provider which included fire safety, safeguarding and infection prevention and control. Staff training records showed that not all training was up to date; however planned dates were in place.

Staff supervision and appraisals had not been carried out in line with the registered provider’s policy. We noted this had been identified during the registered provider’s quality assurance processes and an action plan was in place to ensure all staff were up to date.

People told us they enjoyed the variety and quality of nutrition and hydration provided to them. We observed people making drinks for themselves and saw people had access to snacks outside of mealtimes.

People told us they had regular access to health and social care professionals. Care records confirmed this to be the case.

Since our last inspection, we found that refurbishments had been carried out. A garden room had been designed in the communal lounge on the dementia unit and painting throughout the service had been carried out. At the last inspection we raised concerns about the carpets in hallway of the dementia unit and were told funding had been agreed. At this inspection, they still had not been replaced. We were informed that they had been ordered and replacement would be going ahead shortly.

People told us they were happy living at the service and could spend their time how they wished. People told us they were cared for and felt supported by staff, whom they could go to at any time.

Not everyone we spoke with was sure if they were involved in planning and reviewing their care. However, people we spoke with told us that staff asked their permission before any care and support was carried out.

Staff were aware that people could be supported by the local advocacy service and we could see from the records which we reviewed that one person had used this service.

People told us their privacy and dignity was maintained whenever care and support was carried out and that staff gave them the time they needed and they did not feel rushed.

We observed activities taking place at the service. We saw that people, who attended these activities, actively participated in them. People told us they were happy with the activities provided to them. People attended community events and the service held fundraising events to which the local community was invited.

People told us they knew how to complain and would do so if they needed to. Information about how to make a complaint was available to people and their relatives. We could see that a small number of complaints had been made and records were in place to show the nature of the complaint, the investigation and the outcome of the complaint.

People told us they could approach the registered manager if they needed to. During the inspection, we regularly saw people talking to the registered manager and visiting them in their office when they had questions or concerns.

Staff told us they enjoyed working at the service and felt supported by the registered manager. Staff told us they were kept up to date with events, changes and updates at the service through regular team meetings.

The registered manager was required to update the registered provider each month about all aspects of the service. This meant they were actively monitoring the service and analysing areas such as safeguarding alerts and accident and incident reports to minimise the risk of reoccurrence.

The service worked alongside guidance from visiting health and social care professionals and shared information with the local authority. The registered manager attended safeguarding meetings when required to do so and shared information with them.

The registered manager and staff understood what was expected of them. Notifications to the Commission had been made when required to do so.

We found two breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the premises and equipment and records. You can see what action we told the provider to take at the back of the full version of this report.

Bramble Lodge can provide accommodation for up to 41 people who need help and support and is situated in a residential area within Middlesbrough. Bramble Lodge is a purpose built building over two floors. There are stairs and a lift to assist people to the first floor. Care and support was provided to people on the ground floor living with a mental health condition and on the first floor for people living with a Dementia. At the time of our inspection there were 35 people living at the home.

At the time of our inspection, the manager had been in post since June 2015 and their application to become a registered manager for the service was in progress. 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.

We previously inspected Bramble Lodge on 22 January 2015. At that inspection we found the service was not meeting all the standards which we inspected. We found that the management of medicines was not always appropriate; some medicines had been unavailable for people who needed them and medicine records had not always been completed. Care plans on the mental health unit did not detail 1:1 sessions with people and monthly evaluations of care plans contained limited information. Care plans lacked evidence of care and support should be provided which also enabled people to live to their full potential.

At the start this inspection we could see that the service had not responded appropriately to breaches in records and medicines as identified in our last inspection in January 2015. On the last day of inspection we could see that the service had implemented new procedures for the management of medicines but further improvements to records were required.

At this inspection we could see that safeguarding alerts had been made when needed. Records had been completed appropriately. All staff knew how to respond to a potential safeguarding alert. Staff knew the procedures to follow if they had any concerns and if they had information they needed to share.

Risk assessments were in place for people and for the day to day running of the service. This meant that the service had acted appropriately to reduce the risks of harm to people, staff and visitors.

There were sufficient staff on duty to provide care and support to people and to ensure the smooth running of the service. People and staff told us that there were enough staff on duty to meet people’s needs safely. We could see that staff had been through a thorough recruitment process which included an interview, reference checks and a disclosure and barring service check.

Appropriate arrangements were in place to manage medicines. Medicine administration records were fully completed and good stocks of medicines were in place for people. Guidance for ‘as and when needed’ medicines was available.

People and staff had access to the equipment they needed. We found that equipment was well-maintained.

We could see that staff had completed a variety of training, such as fire safety, infection control and manual handling. Some training had not been completed by all staff; however we could see that this training had been booked in to be completed in the near future.

Supervision and appraisal was not up to date for all staff; however we could see that planned dates had been put in place. An action plan had been put in place by the service to make sure that the registered provider’s guidelines for staff receiving supervision and appraisal would be met by April 2016.

Mental capacity assessments had been appropriately carried out and deprivation of liberties safeguards had been carried out for people who needed them. Records showed the reasons for this decision making and the people involved.

The staff team at the service worked together to monitor people’s weight and to provide appropriate support with nutrition and hydration when needed. People spoke positively about the menu provided at the service.

Health professionals regularly visited the service to provide care and support to people and this was reflected in people’s care records. Consent had been sought when people were given vaccinations.

We could see that staff had a good relationship with the people they cared for. Staff had good knowledge about people’s life histories and demonstrated a good understanding of how people’s health conditions affected them on a daily basis. Staff provided encouragement and support to maintain people’s independence.

Records did not always show if people who used the service were involved in planning their care and making decisions. We found gaps in people’s records and records relating to the running of the service.

The service had not responded appropriately to breaches in records and medicines as identified in our last inspection in January 2015.

People knew how to make a complaint if they needed to and staff were aware of the procedure they needed to follow if they received a complaint. Information to make a complaint was on display at the service.

A new manager was in place at the service and they had submitted an application to the Care Quality Commission to become a registered manager. People who used the service and staff spoke positively about the manager and felt able to discuss any concerns with them.

A skilled staff team was in place at the service. Staff worked as a team to provide care and support to people.

The service had good procedures in place to monitor the quality of the service. Regular audits had been carried out; however medicine and record keeping audits had not highlighted the gaps which we had during our inspection. Feedback was regularly sought from meetings and surveys.

Accidents and incident’s had been recorded and analysis had been carried out to identify any patterns and trends to minimise the risk of harm to people who used the service and staff.

We found one breach in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the premises and equipment and records. You can see what action we told the provider to take at the back of the full version of this report.

At this inspection we found that the manager had worked with staff to ensure all care records accurately reflected people's needs and the care being delivered. We found that the care records were accurate. The provider has also commenced work looking at the care model being used. The manager showed us the new assessment tools and care plans they had developed. These were seen to be much more informative.

The people we spoke with told us 'It is a good home and I like it here', 'I have no problems,' and 'I like it here'.

Concerns had been raised around how staff worked with people overnight so we visited early in the morning and spent eight hours at the home. During the visit we spent time observing care practices, talked with six people who used the service, all five night staff, three day staff, two nurses on duty during the day, the deputy manager and manager. We found that staff appropriately supported people and now ensured each person made choices about what they wanted to do. We saw that staff were attentive to people's needs and treated each person with humanity and empathy.

Staff were aware of the requirements of the Mental Capacity Act 2005 and when appropriate used deprivation of liberty safeguard authorisations. Staff understood the difference between a limitation, restriction and deprivations and appropriately used 'best interest' decision-making powers for people who lacked the capacity to make independent choices. Staff had also ensured advocacy provision was available for people who needed support.

People said, 'They are good to you here'', ''The staff are very nice', 'They are nice here'' and ''I have no complaints, the staff do a good job.''

During the visit we spent time observing care practices, talked with five people who used the service; all five night staff; two day staff; and the temporary manager. We found that staff appropriately supported people and now ensured each person made choices about what they wanted to do. Staff had up dated the care records to show if people had the capacity to make independent choices or if they needed support in this area.

People said ''It is great here'', ''The staff are very nice', 'I do like it here'' and ''I have no complaints it is great here.''

We found that although the staff used the Mental Capacity Act 2005 and Mental Health Act 1983 (amended 2007) further staff training was needed to support staff to apply the legislation to their everyday practice. Also the care records needed to be rationalised and staff needed to provided sufficient detail around how to meet people's needs.

At the visit we spent time observing care practices and talked with eight people who used the service as well as the majority of staff who were on duty. Several of the people at the last inspection said that they wanted to go out on their own and felt safe to do but staff prevented them from doing so. We spoke with these people and found that staff practices had changed and they were now able to go out independently.

We found that staff ensured people were appropriately supported and now actively ensured each person made choices about what they wanted to do. People said ''It is better here'', ''I find the staff are very helpful and I do like it here'' and ''I have no complaints it is great here''. One person raised their concerns about a possible staff member's behaviour, which we shared with the new manager who undertook to investigate the issue.

We found that although the staff understood the Mental Capacity Act 2005 and Mental Health Act 1983 (amended 2007) action was needed to ensure the service adhered to all of the requirements of this legislation.