About the service: Braintree Nursing Home is a residential care home that was providing personal and nursing care to 45 people aged 65 and over at the time of the inspection.

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

People’s experience of using this service:

Staff understood the risks to people and the measures in place to keep them safe. Systems were in place to manage people’s medicines safely and to reduce the risks associated with the spread of infection.

Sufficient numbers of staff were employed to meet people’s needs. Staff received training that gave them the necessary skills and knowledge to carry out their roles and meet the specific needs of people using the service. Champions were promoted in the service. These are staff that have shown a specific interest in areas, such as promoting dignity and are essential in promoting best practice, by sharing their learning, acting as a role model for other staff. This ensured people received good quality care.

People were provided with the care, support and equipment they needed to stay independent. Staff were kind and caring and had developed good relationships with people using the service.

People were supported to maintain their health and had access food and drink based on their individual choice and preferences. People had access to a wide range of activities in the community and within the service, that reflected their specific needs and interests.

People’s communication needs had been assessed and were meeting the requirements of the Accessible Information Standards. This set of standards sets out the specific, approach for providers of health and social care to identify, record, share and meet the communication needs of people with a disability, impairment or sensory loss.

People's privacy, dignity and rights were respected and upheld. People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible.

The provider had clear and effective systems in place to identify and manage risks to the service and drive improvement. There was an open culture of learning from mistakes, concerns, incidents and accidents. The registered manager and staff worked well with other agencies to ensure people received high quality joined up care.

Rating at last inspection: Requires improvement (Report published 21 February 2018)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up:

Our previous inspection in October 2017 (Published February 2018) identified improvements were needed in relation to recruitment practices, cleanliness and hygiene. There had been a lack of oversight of the service by the provider and the registered manager to ensure the service delivered was of a good quality, and safe.

During this inspection we found the required improvements had been made. We will continue to monitor all intelligence received about this service to ensure that the next planned inspection is scheduled accordingly.

The inspection took place on 06 and 11 October 2017 and was unannounced.

Braintree Nursing Home provides nursing and personal care for up to 51 older people, some of whom have a diagnosis of dementia. There were 48 people living in the service at the time of our inspection. The service consists of two separate buildings referred to as the White House and main house. Both of which are spread across two floors and have communal lounge areas. The two buildings have access to a secure courtyard area with seating and flower beds.

At our previous inspections in May 2015 and June / July 2016 we found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there was a lack of management oversight by the provider. At this inspection we found improvements are still required in relation to the implementation of governance systems to ensure the service is well led and records relating to people's care are accurate.

The service has a registered manager 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.

Before the inspection we received information of concern about poor cleanliness and poor hygiene in the service. Although we found people’s rooms and communal parts of the service were generally clean and tidy, the standard of cleanliness and hygiene in toilets and bathrooms needed to improve. Cleaning schedules, including a deep clean rota are in place; however the last recorded deep clean of toilets and bathrooms was signed for on 16 August 2017. A senior member of staff has recently taken over responsibility for monitoring infection control and has implemented an audit which they are now checking to ensure the service is kept clean.

We received mixed feedback from people, their relatives and staff in relation to staffing levels. People’s relatives felt there should be more staff in the White House, however we saw and staff confirmed there are enough staff available to meet people’s needs. The registered manager has calculated staffing levels to ensure they are sufficient to meet people’s assessed needs and this is kept under review.

Recruitment practices are not carried out robustly to ensure potential employees are suitable to work at the service. Two out of the three staff files did not have references from their previous employer to check their previous conduct and suitability for their new role. We recommend that regular checks of recruitment files are undertaken to ensure all the information needed to demonstrate the fitness of the prospective employee has been obtained.

Overall people’s medicines are well managed; however nursing staff are not always adhering to the provider’s policies and procedures when administering medicines with expiry dates and for the disposal of unused medicines. We recommend that additional competency assessments are carried out by the registered manager to check that staff are reading and adhering to the medicines policy and procedures. This will ensure all medicines are administered correctly, in date and disposed of appropriately.

Systems are in place to identify and reduce risks to people using the service. Staff demonstrated a good awareness of safeguarding procedures and knew who to inform if they witness or have an allegation of abuse reported to them.

Staff receive training to meet the specific needs of people using the service and relevant to their roles. New staff are mentored by an experienced member of staff until assessed as competent to work unsupervised.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible, the policies

The inspection took place on 30 June and 25 July 2016 and was unannounced. At our last inspection on 12 and 15 May 2015, the service was found to be in breach of regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008. Following the publication of the report the provider sent an action plan to the Care Quality Commission stating, how they would rectify these breaches. We followed up these concerns as part of this inspection to see what the provider had done to address the concerns.

Overall we found that the provider had implemented their action plan, however this was still a work in progress. At the previous inspection in May 2015, we found people were not supported in line with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). During this inspection we found that significant improvements had been made. The registered manager and staff understood their responsibilities in relation to the MCA and DoLS. People's best interests had been considered when decisions that affected them were made and applications for DoLS authorisations had been submitted to the Local Authority where restrictions were imposed upon people to keep them safe. However, we also found that there was a lack of management oversight by the provider and that further improvements were still required in relation to the implementation of governance systems to ensure the service was well led and that records relating to people's care were accurate.

Braintree Nursing Home provides nursing and personal care for up to 51 older people, some of whom have a diagnosis of dementia. On the first day of the inspection, there were 51 people living in the service. The service consists of two separate buildings both of which are spread across two floors and have communal lounge areas. The two buildings have access to a secure courtyard area with seating and flower beds.

The service had a registered manager 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.

People told us that they felt safe living in the service. People were supported by sufficient numbers of staff who had undergone recruitment checks to ensure they were safe to work. Staff understood how to protect people from the risk of abuse and knew what action they needed to take to report any concerns in order to keep people safe. Staff were confident to whistle-blow to the registered manager if they had any concerns and were confident that appropriate action would be taken. Staff also knew how to report concerns to external agencies such as the police or social services if any concerns arose.

Care plans provided information for staff that identified people's support needs and associated risks. However, some care plans and risk assessments required information to be updated to ensure staff provided consistent support that met people's changing needs.

Checks on the environment were carried out and emergency plans were in place so that staff knew how to support people in an emergency situation. However, there were no procedures were in place to effectively monitor and maintain clinical equipment such as suction machines and nebulizers and quality assurance systems were not always effective at identifying areas of concern.

Medicines were administered safely. However there were areas where more attention to detail in recording would improve the overall management of medication.

New staff received induction training and a training programme was in place to ensure that staff had the skills and knowledge to perform their roles.

Where appropriate, staff supported and encouraged people at meal times. People were weighed regularly and when necessary referred to healthcar

The inspection took place on 12 and 15 May 2015 and was unannounced.

Braintree Nursing Home provides nursing and personal care for up to 51 people. The service incorporates the separate building formerly known as The White House. At the time of our visit there were 41 people living in the service.

The service had a registered manager 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.

People at the service were not always safe as the registered manager did not ensure that the care and treatment of people was appropriate and met their needs. The service did not effectively manage risks. Whilst systems were in place to carry out individual risks assessments these were not carried out to a consistent standard. Where incidents and accidents occurred, the manager did not have adequate systems in place to analyse the cause and patterns, with a view to questioning or improving practice and minimising risk. Recruitment processes were in place prior to people being appointed. Medications were stored safely and most medicines were administered safely however staff did not always correctly record administration of prescribed creams as required.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and are required to report on what we find. The MCA sets out what must be done to make sure the human rights of people who may lack mental capacity to make decisions are protected. The DoLS are a code of practice to supplement the main MCA code of practice. The registered manager had some understanding of MCA and DoLS but had not ensured the necessary DoLS applications had been made. Mental capacity assessments had been carried out where people were not able to make decisions for themselves, however these assessments were not always reviewed.

People were supported to have a balanced diet and to make choices about the food and drink on offer; however, there were not effective monitoring measures in place where people were at risk of malnutrition. People were supported to maintain good physical health. They had access to a range of healthcare providers such as their GP, dentists, chiropodists and opticians. However, people were not always supported to maintain mental health and wellbeing, as there was a lack of care planning in this area.

Staff provided care in a kind, caring and sensitive manner. Staff knew the people they cared for and spoke to them with respect and in a way which they understood. People were supported to make decisions about their care.

People had their needs assessed but care planning was not always developed in a person-centred way. It was not always possible to establish whether people had received the care they needed in line with their needs as required documentation was not consistently completed. Whilst individual complaints were responded to and action was taken, there was not an effective log of complaints with a view to learning from concerns raised and improving practice.

Staff were motivated and felt supported. The manager was committed to supporting people, their families and professionals to contribute their views but did not always respond in a positive way and feedback was not always used to improve the service. The manager had not put in place effective measures to assure themselves that safe and person-centred care was being provided.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report.

As part of our inspection, we spoke with nine people who used the service and three relatives. We also spoke with three members of staff, the registered manager and deputy manager. We looked at five people's care plans. We also looked at the provider's arrangements for obtaining and acting in accordance with the consent to care and treatment for people who used the service. We also looked at medication practices and procedures, service arrangements to monitor the quality of the service and for ensuring there were sufficient staff on duty and skill mix of the staff to provide the care service to people. We observed staff practices during our inspection to ensure that people who used the service were treated with respect and dignity.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a member of staff checked our identification. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

Two people told us they felt safe living in the service and enjoyed the enclosed garden. They also told us that they would feel able to speak to the manager and staff if they had concerns. We saw that all staff had received training in safeguarding of vulnerable adults from abuse as part of their induction and on-going training refreshers. This meant that staff were provided with the information that they needed to recognise signs of abuse and knew how to respond to any suspected abuse.

We reviewed staffing records regarding The Mental Capacity Act (MCA) 2005 in relation to Deprivation of Liberty Safeguards (DoLS) and saw this training was up to date and further training was planned for June and October 2014. The CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Three staff spoken with were able to demonstrate a knowledge and understanding of MCA and DoLS. The registered manager informed us that no DoLS were in operation at the time of our inspection. While no applications have needed to be submitted, correct policies and procedures were in place.

Is the service effective?

People who used the service received regular support and access from a variety of health and social care services and professionals as their conditions and circumstances required.

People who used the service had a care plan in place detailing their specific care needs and the support to be provided by staff. The plans were updated as required and reviews were held each month.

Is the service caring?

One person said. “They look after me so very well, can’t find fault.”

Our observations showed that people who used the service were respected and treated with dignity by staff.

Is the service responsive?

There were appropriate arrangements in place for reporting of complaints and responding to concerns. People's preferences and diverse needs had been recorded in accordance with people's wishes. There were no restrictions upon visiting times and the service co-operated with other providers to meet people’s assessed needs.

Is the service well-led?

There were systems in place to assess and monitor the quality of the service provided. The views of the people who used the service and staff had been sought. The registered manager and deputy operated an open door style of management so they were available to people who used the service and staff to support and resolve issues.

We found that the service provided safe care to people who used the service. The care was delivered in an effective manner that met the needs of those using it. We found that people were protected from the risks of inadequate nutrition and hydration because the service had effective methods of supporting people’s nutritional needs. We found that the service had appropriate arrangements in place for obtaining consent to care.

Observations of the staff providing care throughout the inspection demonstrated that the staff cared for the people they supported. We spoke with eight people who used the service who all told us that they felt cared for by staff. One person told us, “The staff are so lovely, really caring.” Another told us, “They always make time for me. Nothing is too much for them.”

We spoke with three relatives of people using the service. All told us that they felt listened to and could talk to the management team about anything. One relative told us, “I don’t need to make an appointment if I want to talk about something they make themselves available. They always sort things out and support us.”

Our inspection was conducted on Saturday. We saw that there was effective leadership on duty on the day of our inspection. This ensured that all people’s needs were met.

We found that the records were not always accurate, up to date or fit for purpose. Documents required for the purpose of the inspection could not be located when required.

This inspection was completed by three people and included an expert by experience and a professional adviser. We inspected six outcomes and found the service compliant.

People told us how satisfied they were with this service because it had a homely atmosphere and they were treated with dignity and respect at all times. A typical comment was “My daughter found this place for me, and I am so glad. It is kept so nice and clean, and nothing is too much trouble for the staff. In the evening I like to go into my room, and I spend time sitting in bed watching TV. I’m normally in bed by about 7.00pm. I could stay up until 10.00pm if I wanted, but I always feel quite spoilt sitting in bed watching the television – how fortunate am I?”

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People were getting sufficient nutrition and hydration and nursing interventions were making a real difference because wounds were healing.

We concluded there were enough qualified, skilled and experienced staff to meet people’s needs. We examined rosters, spoke to staff and people at the service, and observed practice. Staff had undertaken several recent training courses and this included, wound management, medication and manual handling.

All people we spoke with told us they or their relative were happy living at Braintree Nursing Home. We observed that people were given opportunities and choices throughout the day with people attending some planned activities on site. Several people we met were going to the hairdresser for hair appointments. People who live at Braintree Nursing Home looked smart and well cared for.

We spoke with an individual who spends most of their time in bed. They told us they were comfortable with the air mattress and that “Staff were friendly and nice to them”. They also told us that occasionally they got “Thirsty”, but had to wait for staff to come and help, although they said, “They do come regularly”.

We spoke with five relatives and all were positive and satisfied with the care and treatment that their relative was receiving at Braintree Nursing Home. One relative told us that they were involved in planning their relatives care and support and believed that their relative was looked after well. One relative was hoping for more planned activities, but said they were new to the service so was waiting for matters to develop.

One relative told us that when they were very satisfied with the carers and that they had “Not seen anything that would suggest people are not looked after well”.

The feedback from all people and visitors spoken with was positive about the staff at Braintree Nursing Home. We observed that relationships between staff and people were friendly, warm and appropriate.

Where people were unable to provide a verbal response or tell us verbally their experiences, for example as a result of their limited verbal communication or poor cognitive ability, we noted their non verbal cues and these indicated that people were generally relaxed and comfortable.

Comments from people who use the service about the care and support provided at Braintree Nursing Home were complimentary. People told us they were happy living at the home and that they were pleased with the care and support provided by staff. People also told us that they were treated well by care staff and that their privacy and dignity were respected.

People we spoke with said they were satisfied with the way that the home manages their medicines.

During our visit we were able to hold a conversation with two people and they were able to make comments about specific issues, such as the quality of the meals, whether or not they liked their room and if they liked staff. However, most of the information about people’s experiences was gathered through our observations. They also told us that they felt safe and that, if they had any concerns or worries, they would discuss them with their relative or a member of staff.

One relative with whom we spoke, told us, that they were happy with the care and support their relative received. One compliment was recorded and this told us “Thank you most sincerely for the exemplary, loving care that you gave our relative. We cannot speak too highly of your kindness, professionalism and unfailing good humour in what must be at times a most difficult and taxing job.” Comments made within two satisfaction surveys, issued by the provider, from relatives recorded “Overall we are very happy with the service” and “A friendly relaxed ‘homely’ atmosphere.”

The three people with whom we spoke said they were happy at the home and that they enjoyed the food. One person told us they would like the food to be a little warmer. They were happy with the management of their medication and received their medicines on time. They said staff were very helpful.