Archived: The Brambles

The Brambles is a residential care home providing personal care to up to six people with a learning disability and/or autism. At the time of the inspection there were two people living in the home. During the course of the inspection both people were supported in planned moves into new services.

The Brambles is an adapted residential building located close to local amenities. Accommodation is spread across two floors. There are six ensuite bedrooms, a shared living space and kitchen and secure garden.

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

The service had made considerable improvements since the last inspection. There was a clear plan of action which had been completed to ensure the service was now safe, effective, caring, responsive and well-led.

There were policies and procedures in place which were followed to protect people from abuse and the risks of avoidable harm. People had risk assessments and care plans which supported them, helped reduce risks and promoted their independence.

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 were caring towards people and understood how they expressed themselves. The service had worked to improve focus on promoting people’s life skills and independence. Staff supported people to participate in activities which interested them, and had supported people through the pandemic to keep in touch with loved ones.

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.

This service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The service was small and gave people access to the local community. People’s independence was promoted in how they were supported for personal care and activities. Staff understood how to maintain people’s dignity and treated them with respect. There were clear values established for staff and role modelled by senior staff to ensure the culture was inclusive.

Right support:

• Model of care and setting maximises people’s choice, control and independence.

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human rights.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

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 13 February 2021).

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 and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 3-14 September 2020. Breaches of legal requirements were found related to safe care and treatment, and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements.

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.

You can read the report from our last inspection, by selecting the ‘all reports’ link for The Brambles 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.

The Brambles is a residential care home providing personal care to up to six people with a learning disability and/or autism spectrum disorder. At the time of the inspection there were four people living in the home.

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

People using the service were not always safe as the service had not fully assessed and put in place measures to reduce risks to their health, safety and wellbeing. This included management of their risks from Covid-19.

There had been improvements in the management of medicines. The service had responded to medicines errors and had sought an alternative administration method to reduce the risk of errors.

There had been some improvements in the reporting of incidents, however further improvements were required to ensure any learning could be identified. Staff had a good understanding of what needed to be reported internally as an incident and about types of abuse that needed reporting.

We identified records were not always up to date, complete or accurate and systems to review the quality of the service did not always identify issues for improvement.

The management team were aware of the culture in the home and were working to promote a more proactive approach within the staff team which promoted people’s independence. Staff told us they felt supported by the team and worked well together. Most staff felt confident to raise concerns, however one staff member told us they did not feel information was kept confidentially.

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.

Right support:

• Model of care and setting maximises people’s choice, control and independence

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human rights

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. The environment was suitable for people to live a life like any other citizen. The service is small and located in a residential area with access to local facilities.

Staff understood how to promote independence. Records could be improved to ensure this was consistent. We could not be assured that risks were considered in line with best interest and least restrictive practices. Some aspects of care planning were not person-centred and it was not clear how people’s skills were being built upon to further improve their choice, control and independence.

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 19 November 2019).

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 that some improvements had been made, however the provider had not made sufficient improvement and so was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on actions we told the provider to take at the last inspection.

We previously carried out an unannounced comprehensive inspection of this service on 29 August and 04 September 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe and Well-led which reflect those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

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

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 continued breaches in relation to safe care and treatment and good governance at this inspection.

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 will request an action plan from 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.

The Brambles is a residential care home providing personal care for up to five people living with a learning disability, autism spectrum disorder or Down’s Syndrome. At the time of the inspection there were five people living in the home.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a small home which fit with the local domestic style properties. It was registered for the support of up to five people, in line with best practice guidance. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. 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

Risks to people’s safety and wellbeing were not always managed effectively, which put people at risk of harm. Infection control and fire risks were not managed safely and people did not always receive their medicines as prescribed.

Though some support interventions were effective and achieved positive outcomes, not all support plans reflected best practice and professional advice. Risks relating to eating and drinking were not effectively managed.

The service didn’t always consistently apply 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 did not fully reflect the principles and values of Registering the Right Support for the as they had limited choice and control and were subject to unjustified restrictions of their liberty.

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.

The service did not have effective measures in place to ensure that quality and safety issues were identified and addressed in a timely way. Records were not always up to date, accurate, complete and available. The home was going through a period of change and staff reflected there was an improving picture. Some areas highlighted on this inspection had been identified by the management team as areas for improvement, and some improvements had been made.

People’s interests and preferences were taken into account and they had access to activities which reflected this. People were supported to avoid social isolation. Some staff had a very kind and patient approach, where others were directive and did not treat people with respect.

The service did not consider people’s wishes ahead of reaching the end of their life. We recommended the service apply guidance on advanced care planning, so that people and those important to them can have their wishes and preferences considered ahead of making urgent care decisions when they become unwell.

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

Rating at last inspection

The last rating for this service was good (published 16 March 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches of regulations in relation to managing risks of people’s health and wellbeing; using disproportionate restrictions of people’s freedom and control; failing to treat people with dignity and respect and failing to implement robust quality assurance measures 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.

We last inspected The Brambles on 30 September and 1 October 2015 and found the provider to be in breach of regulations in relation to staffing and good governance. We issued warning notices for the breaches of regulations. The provider was required to meet the regulations relating to the warning notices by 31 January 2016. During this inspection we found the provider had taken action to ensure the requirements of the regulations had been met.

The service did not have a 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 previous registered manager had deregistered on 11 August 2016. A recently appointed home manager was currently responsible for the day to day running of the home. They had submitted an application to CQC to become the registered manager.

People were protected from abuse because staff were trained and understood the actions required to keep people safe. Staff had completed the provider’s required safeguarding training and had access to guidance to help them identify abuse and respond appropriately if it occurred. Staff were able to demonstrate their role and responsibility to protect people.

Risks specific to each person had been identified, assessed, and actions implemented to protect them. Risks to people had been assessed in relation to their mobility, social activities and eating and drinking. Staff were able to demonstrate their knowledge of individual risk assessments and how they supported people in accordance with their risk management plans.

The home manager completed a daily staffing needs analysis to ensure there were always sufficient numbers of staff with the right skills mix and experience to keep people safe. We reviewed staff rotas between January 2016 and September 2016 which confirmed that people had been supported by sufficient numbers of suitable staff to keep people safe, in accordance with the staffing needs analysis, including times when increased staffing ratios were required.

Staff had undergone pre- employment checks as part of their recruitment, which were documented in their records. These included the provision of suitable references in order to obtain satisfactory evidence of the applicants conduct in their previous employment and a Disclosure and Barring Service (DBS) check. Where DBS checks had raised concerns over candidates suitability these issues had been explored in depth by the home manager and subject to risk assessments, to confirm they were suitable for employment.

People received their medicines safely, administered by staff who had completed safe management of medicines training and had their competency assessed annually by the home/registered manager. Staff were able to tell us about people’s different medicines and why they were prescribed, together with any potential side effects. Staff supporting people in the community ensured they took the person’s prescribed emergency medicine in case they experienced a seizure, which was effectively recorded.

The provider’s required staff training was up to date, including safeguarding people from abuse, moving and positioning, the Mental Capacity Act 2005, fire safety, food hygiene and infection control. This ensured staff understood how to meet people’s support and care needs. Training was refreshed regularly to enable staff to retain and update the skills and knowledge required to support people effectively. The provider had recognised that staff required further training to meet people’s specific needs, for example; training in relation to autism, intensive interaction and Makaton language. Makaton is a language programme using signs and symbols to help people to communicate. Records and staff confirmed this training had been completed. Training was refreshed regularly to enable staff to retain and update the skills and knowledge required to support people effectively.

Staff had received regular individual supervisions from their supervisors, and monthly group supervisions, where aspects of training were also refreshed. Bi-monthly staff meetings had protected time in the home calendar to ensure attendance. Records demonstrated that the previous registered manager, deputy manager and team leaders had completed courses relevant to their role and responsibilities, for example; all of the management team had completed a management course in relation to effective supervision.

Staff supported people to make as many decisions as possible. People’s human rights were protected by staff who demonstrated a clear understanding of consent, mental capacity and deprivation of liberty legislation and guidance.

The home manager and staff demonstrated that a process of mental capacity assessment and best interest decisions protected people’s human rights. The provider ensured that all best interest decisions by visiting health professionals were effectively recorded within people’s care records, as well as their medical notes.

People were supported to have enough to eat and drink and were provided with a balanced, healthy diet. We observed the provision of meals during breakfast, lunch and dinner time. People were supported to consume sufficient nutritious food and drink to meet their needs, in accordance with their care records.

Records showed that people had regular access to healthcare professionals such as GP’s, psychiatrists, opticians, dentists and occupational therapists. Each person had an individual health action plan which detailed the completion of important monthly health checks. People were supported to maintain their health and welfare.

People and, where appropriate, their relatives were supported to be actively involved in making decisions about the care they received. Staff had developed positive caring relationships with people and spoke with passion about people’s needs and the challenges they faced. They were able to tell us about the personal histories and preferences of each person they supported. Health professionals made positive comments about the positive impact on people’s well-being due to how well they had implemented their guidance, for example; reducing people’s anxiety.

People’s privacy and dignity were maintained by staff who had received training and understood how to support people with intimate care tasks. Staff were able to clearly describe and demonstrate how they upheld people’s privacy and dignity. They also demonstrated how they encouraged people to be aware of their own dignity and privacy, for example; supporting them to replace clothing and holding personal conversations in private.

The management team completed the local authority training on person centred care planning in February 2016. The management team told us they were committed to ensuring people were involved as much as they were able to be in the planning of their own care. The provider reviewed people’s needs and risk assessments regularly to ensure that their changing needs were met. People’s needs tended to change frequently and plans were reviewed whenever a change was required.

The home manager and provider sought feedback in various ways, including provider surveys, visitor’s questionnaires, house meetings, and staff meetings, which they used to drive continuous improvement in the service. Since our last inspection there had been no complaints raised about The Brambles. People had access to information on how to make a complaint, which was provided in an accessible format to meet their needs.

Staff told us the home manager, deputy manager and team leaders were a source of encouragement to them and made them feel their opinions were valued. Staff were able to tell us about the values of the provider and we observed staff followed these in practice.

Staff told us the management team had improved the culture within the home to make it more open, where people and staff felt safe and confident to express their view. We observed the management team providing one to one support for people regularly during the inspection, which enabled them to build positive relationships with people and staff, which records confirmed.

The home manager had established systems and processes that enabled them to identify and assess risks to the health, safety and welfare of people who use the service and to ensure compliance with legal requirements. The provider had maintained accurate, complete records in relation to people, including a record of the care and treatment provided and decisions taken.

People were provided with a suitable and nutritious diet. Each person had a comprehensive nutritional care plans which identified people's needs, likes and dislikes. We observed how staff appropriately supported people with eating and drinking.

People were protected from the risk of abuse because the staff were aware of the different types of abuse and how to report a concern. A relative we spoke with told us that they felt people living in the home were safe and well cared for.

There were adequate levels of staff on duty on the day of inspection with appropriate skills and qualifications. We found people were supported in line with their plans.

The provider had an effective system to assess and monitor the quality of service. People were asked for their views and the provider acted upon these, where appropriate.

We were invited to look at two of the people's bedrooms and could see that these provided a clean, comfortable and homely environment.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare

People were called by their preferred name and staff treated them with dignity and respect. We observed people being involved in activities, being read stories and undertaking gentle exercise. Staff used Makaton 'sign' language to help them communicate with those people who were familiar with it.

We spoke with three staff members and the manager. They all told us they felt supported. One told us 'I love my job; this is by far the best place I have worked'. Another said 'there is lots of support, and communication is excellent'. They told us that the training was 'excellent and constantly available'