Bradbury Manor is a care home that provides planned and emergency short term respite care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service can provide accommodation and personal care for up to 10 people at this location some of whom may have a learning disability and/or additional physical care needs. At the time of our inspection there were five people using the service on the first day of inspection and four people on the second day. The inspection took place on 19 and 20 September 2018 and was unannounced.

At the inspection on February 2016 we asked the provider to take action in response to our findings. A planned inspection took place in June 2017 to follow up on the concerns found at the previous visit. At this visit the service received a further rating of requires improvement and one breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, was found. A requirement notice was made against the service.

At this inspection, although we found improvements had been made in some areas, the service continued to be in breach of Regulation 12 for a third consecutive time. We further identified two new breaches, Regulation 17 Good governance and Regulation 18 Notification of other incidents. The service was rated requires improvement for the third consecutive time and we are considering what action will be taken in response. Full details of CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

A registered manager was in post and available throughout this 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.

We found that notifications of a safeguarding nature had not always made to The Care Quality Commission. Further to this, evidence of the service’s investigations into events were not always recorded, or actions taken and documented, to ensure risks were minimised and people were kept safe.

We reviewed some of the incidents that people had experienced and saw there was not enough detail recorded of the action taken. There was no information on how people were supported, if medical help had been accessed or if actions to minimise the risk of a reoccurrence had been implemented.

The current staffing levels in the home were maintained by a relief bank of staff and agency staff. Staff consistently raised their concerns about the staffing to us.

At times there was a lack of information recorded in care plans for staff to follow. The terminology in care plans and daily records was not always appropriate for the young adults that were being supported. We found that there was no information recorded about how people wished to be cared for if they became unwell or in the end stages of their life.

The provider’s quality assurance systems in place had failed to identify concerns in the service for timely action to be taken, to keep people safe. There was a lack of provider oversight of how the service was operating.

The service had worked hard to make improvements to the mental capacity assessments. The assessments showed that people had been appropriately involved in the process and supported to try and understand the decision needing to be made.

People told us they were treated well and staff were caring towards them. We observed that staff were tactile with people and offered comfort through verbal reassurance and gentle touch.

The management and staff valued the importance of mainta

Bradbury Manor provides planned and emergency short term respite care for up to 10 people some of whom may have a learning disability and/or additional physical care needs. At the time of the inspection there were six people staying at the service for respite care. This inspection was unannounced and took place on 20, 21, 26 June 2017.

A registered manager was in post when we inspected the service but was not available at this inspection due to planned leave. 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. In the registered manager's absence the deputy manager had stepped up to be acting manager and was available to support our inspection. The county manager, who was an allocated manager from the provider Wiltshire Council was also present.

Previously the home had been inspected in February 2016 and was found to be in breach of three of the Regulations. At this inspection we saw that the provider had taken or made steps towards taking, the necessary action to no longer be in breach of two of these regulations.

We have made a recommendation to the provider about recording evidence at the service to show that the required recruitment documentation has been obtained. This was currently been held by the human resources department.

The service did not always manage internal security well in order to prevent any potential safety concerns and protect people’s confidential information. This included access to the cleaning room which contained harmful chemicals, the medicines room with the keys available to the locked cupboards that the medicines were kept in and the office where people’s care plans were kept.

We found that monitoring in the home was not completed effectively in order to reduce the potential of harm to people. This included temperature monitoring for the medicines room, bath temperatures in the communal bathrooms and the kitchen fridge and freezers.

Risks to people’s personal safety had been assessed. Staff had received safeguarding training, and were aware of their responsibilities in reporting concerns, and the concerns of those they supported.

The service had made some improvements in the recording of peoples Mental Capacity and associated documentation. Further improvements are needed to obtain the appropriate consent for care decisions and the information recorded in people’s Mental Capacity assessments.

People’s care records showed relevant health and social care professionals were involved with people’s care. Health action plan were in place which described the support people needed to stay healthy. One health professional told us “They always contact us either by email/phone and make referrals for any changes. I have personally witnessed support for someone in an emergency admission to hospital, where they provided care and support for the individual during their admission.”

People received care and support from staff who had got to know them well and were treated with kindness and compassion in their day-to-day care. There was a sense of calm in the service and people were not rushed by staff but supported at a pace suitable for them. Relatives spoke positively about the service and staff saying “We are very happy with the care, [X] is always happy to go for respite which is always reassuring. They listen to her and she feels safe. The staff are always there for a chat, so they are there for me too.”

Although quality monitoring was in place, areas for improvement including internal security, temperature monitoring, employment checks recording and consent to care had not been identified in order for action to be taken prior to our inspection.

During our inspection we found that the service had not reported an event

Bradbury Manor provides planned and emergency short term respite care for up to 10 people with a learning disability, some of whom may have additional physical care needs. At the time of the inspection there were five people having respite care. This service was last inspected in October 2013 and all standards inspected were met.

A registered manager was 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.

Members of staff had a good understanding of risks and had received training to ensure they were able to use specialist equipment such as suction and percutaneous endoscopic gastrostomy (PEG) tubes. Staff said they supported people who were at risk of choking, pressure ulcers, people who experienced seizures and for people with mobility needs. Risks were not always assessed and some risk assessments lacked detail. For example, risk assessments were developed for people at risk of aspiration (food particles entering the lungs) but lacked detail on how and when staff were to use equipment such as suction to prevent aspiration.

Medicine systems did not protect people’s safety. Staff said their competency to administer medicines was tested annually. Medicine procedures lacked detail on how to protect people from unsafe medicine. For example, developing protocols for “when required” medicines. People were prescribed with “when required” medicines which included pain relief, medicines for maintaining PEG tubes and for people with nebulisers. Protocols were not developed from the guidance provided by specialists. This meant the staff did not have all the guidance needed to administer medicines “when required” by the person.

People’s capacity to make specific decisions was not always assessed, such as the use of audio monitoring systems. Staff had accepted feedback from relatives who did not have power of attorney for care and treatment. Records demonstrated people were vulnerable in the community and needed staff support. We noted there were systems to exit the home and people were not aware of the code to leave the home without staff support. Deprivation of Liberty Safeguards (DoLS) applications were not made for continuous supervision. This meant staff were not working within the principles of the Mental Capacity Act (MCA) 2005.

The views of people were gathered and their feedback was discussed at customer meetings. The manager used this feedback to make improvements to the service. Audit visits from the regional manager were completed every three months. Audits were targeted, for example medicine audits. Where shortfalls were identified action plans with timescales were developed. However audits had not identified staff lacked understanding of the principles of the Mental Capacity Act (MCA) 2005 and that support plans and risk assessment were not in place for all aspects of people’s care and treatment.

Staff were knowledgeable about the day to day decisions people were able to make and during our visit we saw staff enable people to make choices. We observed good interactions between people and staff. Members of staff knew people’s preferences, their likes and dislikes and how they wanted to be addressed. Support plans were not always developed on all aspects of people’s needs and guidelines were not always kept together.

Safeguarding of vulnerable adults from abuse and whistleblowing procedures were on display. This meant members of staff had access to guidance on the types of abuse and the actions to be taken for suspected abuse. The staff we spoke with were able to describe the types of abuse and the actions to be taken if they suspected abuse. The two people we spoke with said they felt safe and the staff made them feel secure.

The service provided short break accommodation with care, mainly to people who stayed there regularly. One person told us “I always have my own key when I’m here. It’s here, look. No-one can go in unless I want them to.”

We saw the analysis of feedback from people who had used the service at Bradbury Manor. One person had written "I think it’s brilliant. I always look forward to coming in.”

The documentation we reviewed, and discussions we had confirmed that people’s needs were assessed and then care and treatment was planned and delivered in line with their care plan. This documentation contained risk assessments for each person. These were written in easy-to-read language. The assessments were based on attempting to ensure people could do things, rather than stopping them from becoming involved in situations which might be a risk.

It was clear that staff understood the requirements of the safeguarding policy and followed the correct procedures. Concerns had been dealt with appropriately.

We saw documentation regarding induction, supervision and appraisal, which confirmed that staff received appropriate professional development. People told us they were confident about the ability of the staff who looked after them.

We heard and saw evidence which confirmed that the manager was concerned to improve the quality of service for the people who used Bradbury Manor, through understanding learning from feedback and from elsewhere.

People stayed at the home for short breaks. They were encouraged to bring personal items with them for their stay. When possible, people could occupy the same room each time they came, so it would feel familiar. A person staying at the home told us they knew staff well, which made it easy to settle each time.

There was a games room with a pool table and lots of games and pastimes. Staff told us many people chose to stay up late to watch television or to chat with each other or staff members. We saw people being supported to go out for a pub lunch. There were enough staff to support them and the people who chose not to go. We saw the staffing level was varied to suit the needs of people staying at the home at any time.

Staff were friendly and respectful to people. They had guidance on meeting people’s communication needs and we saw they were skilled in communicating with people.

The home had an arrangement with a local surgery to register people as temporary patients, so medical attention was available if necessary. Support plans gave staff detailed guidance about people’s care needs, including how to use any equipment.

There were safe arrangements for keeping people’s money if they wished. Staff were trained in recognising if people might be at risk, and what to do if they had concerns for people’s safety.

At our second visit, to the provider’s offices, we found there were similar training and supervision arrangements for both permanent and relief staff.