Archived: Brackley Lodge Nursing Home

Brackley Lodge Nursing Home is registered to provide nursing and personal care for up to 30 people living with a physical disability, dementia and those who require care for adults over 65 years. At the time of this inspection there were 20 people living in the home.

In April 2015 we rated the home as providing an overall ‘Inadequate’ level of care and support to people and we placed it into special measures. This was due to serious concerns about the safety and well-being of the people who lived there. The provider agreed not to admit any new people until they had improved the care provided and also gave an undertaking to ensure that there was a registered general nurse on all of the shifts, to ensure effective clinical leadership. The service was taken out of special measures following an inspection in September 2015 which found significant improvements had been made.

However since January 2016 there had been an escalation in concerns about the safety and adequacy of the care and support provided to people living in the home. The Local Authority and health commissioners’ monitoring officers expressed particular concerns about the overall clinical oversight of the home, staff knowledge and training and a number of safeguarding issues had been raised as to potential neglect of people. In light of these concerns we brought forward a planned inspection.

The service is required to have a registered manager; there was no registered manager at the time of the inspection which has been the situation since April 2015 when the registered manager left. Attempts had been made to secure another registered manager but they had all failed.

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 provider had employed an acting manager who was in the process of applying to be the registered manager. This person had since left and the provider had recruited another acting manager who was in the process of submitting an application to become the registered manager.

In addition to the collapse of sufficient management arrangements, there was no permanent clinical lead. The provider was relying on agency staff to take the clinical lead without the understanding and oversight of the people living in the home. Staff without managerial experience or the qualifications were left in charge. There had been a high turnover of staff which meant that people were not always being cared for by staff that knew them and understood their needs.

People were not being cared for in a safe and timely way. There was insufficient staff to meet the individual needs of people and there was no clinical oversight. The provider was failing to ensure that an RGN was on duty each shift having previously given an undertaking that this would happen to ensure that people’s physical health needs were being appropriately monitored.

Only basic care was being provided and people’s choices were being limited due to the level of staff deployed. People’s nutrition was not being consistently and accurately monitored and people were losing weight. Mental capacity assessments were not always being undertaken for people who were unable to make decisions for them self.

The systems that were in place to monitor the service and support its development were no longer being followed. Care plans and risk assessments were not being kept up to date which was putting people at unnecessary risk. Different staff were expected to monitor the administration of medicines without the knowledge and oversight of the system.

People’s choice and freedom to move around the home was impacted due to the poor staffing levels and staff were not receiving the guidance and support they needed to do their jobs well.

There had been a high turnover of staff and staff had not been given the training to equip them to meet some of the specific needs of people that lived at the home.

The leadership, quality monitoring and governance arrangements had collapsed and needed to be re-established. Records were not accurately being kept; audits had not been completed for some time so there was no steer to drive improvements. There was an absence of day to day clinical and managerial leadership.

We identified a number of areas where the provider was in breach of Regulations of the Health and Social Care Act 2008 (regulated activities) Regulations 2014 (Part 3) and you can see at the end to this report the action we have asked them to take.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC as the provider has been unable to sustain the improvements it had made following being taken out of ‘Special measure’ in September 2015.

The purpose of special measures is to:

· Ensure that providers found to be providing inadequate care significantly improve.

· Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

· Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

This is the second occasion that this service has been placed in special measures and we will be considering the action that we should take to secure the safety and well being of people living in the home. The service will be kept under review and if needed could be escalated to urgent enforcement action.

This is a summary of what we found-

Is the service safe?

Staff recruitment systems were robust and staff received thorough induction training before being allowed to work unsupervised. This meant that people were protected from the risks associated with the appointment of new staff.

Is the service effective?

Additional care staff had been recruited to meet the needs of people who used the service. In addition more housekeeping staff had been recruited freeing nursing and care staff to focus on the care and support that people who used services required.

Is the service caring?

We saw that staff treated people with consideration and respect and sought their consent before providing support or care. Staff referred to people by their preferred name and involved them in decisions about their lives. We saw people were treated as individuals and staff encouraged people to participate in activities and conversation.

Is the service responsive to people's needs?

We saw that staff responded swiftly to meet the needs of the people who use services and call bells were answered promptly.

Is the service well lead?

The provider sent us an action plan that set out the improvements they were going to make to the service. This included increased staffing levels at the busiest times, changes to arrangements for meal times to reduce waiting times and increased staff supervision.

This is a summary of what we found-

Is the service safe?

All of the people we spoke with told us they felt safe living at Brackley Lodge, one person said 'The staff are all very kind; I have never had any nasty stuff'. Individual plans of care contained risk assessments to promote people's safety such as risk assessments for malnutrition, the risk of falls, the use of bedrails, the effects of pressure on the body and movement and handling. We also observed staff used safe movement and handling techniques including the use of equipment such as hoists.

We saw bedrooms were fitted with appropriate safety equipment such as window restrictors, radiator guards, call bells and fire doors were fitted with automatic closure devices. We found both the bedrooms and the communal living areas were either fitted with non-slip flooring or carpets. No other slip or trip hazards were identified. We looked at the accident records and found that there had been no accidents where the cause had been attributed to the safety of the environment.

We found that staff had the right checks before they started working in the home and that staff had the right training to ensure people were safe. The management conducted the right checks to ensure that people were safe.

Is the service effective?

All of the people living at Brackley Lodge had an individual plan of care; these had been regularly reviewed to ensure that they contained appropriate information.

We saw people were comfortable and relaxed within their environment, people looked well cared for and they were dressed according to their age, gender, culture and the weather conditions. We saw that people had access to a range of aids and adaptations to support their independence and mobility.

However staffing levels had not been maintained at an appropriate level in relation to the collective needs of the people who used the service, this meant that the quality of care that staff were able to provide had been compromised.

The provider may wish to note that the layout and d'cor of the communal areas and corridors had not been adapted to meet the recommended standards and needs of people with dementia. We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to Staffing.

Is the service caring?

People had mixed views and experiences about the way they were cared for. We saw that staff were generally mindful of people's privacy however we saw that people were not always treated with respect and consideration. For example one person said 'Usually, the staff don't ask me about my views, they just do it, they know best, I trust them'. Another person said 'The staff have their days; we just have to put up with it'.

We also observed that at times the behaviour of some staff was not respectful and their comments did not promote the dignity of the people who used the service. For example prior to the lunch time service we observed that some staff worked at a rushed pace without explaining what they were doing, or why they were doing it. We also observed that people who used the service were sometimes referred to as 'love' or 'dear' rather than their preferred name.

We also saw there was very little social interaction between the staff and people who used the service, except when people were served. We observed the majority of people were seated in the dining room waited between 40 and 50 minutes before their lunch was served. We saw that the behaviour of some of the staff was brusque; as staff brought plated meals into the room one person was served their meal in an offhand and careless manner.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to respecting and involving people who use the service and staffing.

Is the service responsive to people's needs?

Staffing levels had not been maintained at an appropriate level in relation to the collective needs of the people who used the service; this meant that the quality of care and support that staff were able to provide had been compromised.

People with dementia lacked objects of stimuli to engage with. There were no magazines, books or newspapers (magazines, books, newspapers are helpful in matching people's past identity with respect to their occupation, hobbies, or interests). We also noted there were no 'tactile' objects; sensory objects, or any other items to promote stimulation and reminiscence. The provider may wish to note that the lack of appropriate stimulation is known to impair the quality of life that can otherwise be achieved for people with dementia.

We saw that people had access to appropriate aids and adaptations to promote their independence and mobility. We also observed staff using safe movement and handling techniques including use of equipment such as hoists. Records showed that people had access to appropriate pressure relieving equipment. Records also showed that people had access to health professionals and NHS services.

People told us that staff were unable to provide some of the activities because other staff had to work in the laundry and had to 'stand in' for the cook and laundry staff for two days.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to Staffing.

Is the service well lead?

The registered manager and the provider had had conducted the appropriate checks to ensure that people who used the service were safe. Staff recruitment systems ensured that people were protected from abuse and unsafe care. Systems were in pace to ensure that staff had the right skills to care for people safely. Individual plans of care reflected people's health care needs and personal preferences. Risk assessments were in place to reduce and manage the impact of identified risk factors.

All of the people we spoke with told us that they felt safe living at Brackley Lodge and that the staff were kind to them. One person said 'I am well looked after here'.

We saw that people were supported to maintain and adequate fluid and food intake. We also saw that the meals provided were home cooked, were of an adequate portion size and available as a soft diet.

People who told us they thought there were enough staff who had the right skills to care for them safely; one person said 'the staff are very good here'. They also told us they thought the staff had the skills they needed, to care for them and that they were well looked after by the staff who worked at Brackley Lodge.

We spoke with three people during our inspection at Brackley Lodge; the service provides care for people with a range of needs, some of whom have dementia. As such people were limited in their ability to recall or express their views. In these circumstances observations were used to inform our inspection.

One person told us that the staff involved them in decisions about their care and explained their care needs to them before carrying out any procedures. This meant that people were provided with information to enable them to make informed decisions and provide informed consent to the care and treatment that was offered.

All the people we spoke with indicated that they were well looked after at Brackley Lodge and that the staff knew how they needed and wished to be supported. They also told us that there were activities that they could join in with if they wanted to.

People told us that they felt safe living at Brackley Lodge and we saw that people were relaxed and comfortable in their communications with staff.

they also told us that the staff supported them to take their medication safely.

One person told us that they thought that the staff had the right skills to care for them safely. One person said 'most of the staff are very good, a relative also told us that they thought that the staff cared for their relative very well.