Breme Residential Care Home is registered to provide accommodation for up to 60 older people who may live with dementia, physical disability or and sensory impairment. Accommodation and care is provided for people living at the home on both a short term and permanent basis. There were 55 people living at the home at the time of our inspection.

The inspection was unannounced and took place 21 February 2017. We arranged with the registered manager to return on the 22 February 2017 to finish our inspection.

A registered manager was in post at the time of our 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. The registered manager was supported by a manager, who was responsible for the day to day management of the home.

At the last comprehensive inspection on 16 and 17 October 2014, we found improvements were required in the way people’s medicines were managed and in staffing levels to support people. At this inspection we found the improvements required had been made. There were enough staff to care for people and to respond to their needs so they received the individualised care they needed. Improvements had been made in the way people’s medicinal creams were administered.

People told us they received the support they needed from staff to feel as safe as possible and told us they were confident staff would take action to make sure they were safe and well. Staff knew what action to take to protect people from the risk of potential abuse and understood how to balance the risks to people’s individual safety with their desire for independence.

People benefited from receiving care from staff with the knowledge and skills support them and recognise their rights. Staff took action to provide the care people agreed to. Where people needed support to make some key decisions about their lives staff took action to do this in ways which took people’s best interests into account. People were encouraged to have enough to eat and drink to remain well and people enjoyed their mealtime experiences. Staff took action to support people if they required medical assistance, and the advice provided by health professionals was followed, so people enjoyed the best health outcomes possible.

Caring relationships had been built between people and staff and people and their relatives were positive about the staff that supported them. Staff took action to make people feel valued and included. Staff used their knowledge of people’s interests and histories and took time to chat to people so they did not feel isolated. People were offered reassurance from staff in the ways they preferred when they were anxious. People were encouraged to make their own day to day decisions about their care. Where people needed support to do this this was given by staff. People’s rights to dignity and privacy were understood by staff.

People and their relatives were comfortable to make suggestions about the care people received, so their preferences would be met and risks to their well-being responded to. Where people were not able to make all of their own decisions their representatives and relatives were consulted. Staff recognised when people’s needs changed and adjusted the way they cared for people so their needs would continue to be met and their well-being enhanced. Systems for managing complaints were in place, so any lessons would be learnt.

Positive comments were made about the way the home was managed and the culture of the home. People were encouraged to see Breme Residential Care Home as their home and felt included in the way it was run. People, their relatives and staff were encouraged to make suggestions for developing care further and were listened to by the

There were 58 people living at Breme Care Home when we carried out our inspection. We looked at how care was provided to people with dementia. There were six people who lived on Mulberry unit and 24 people on the second floor at the time of our inspection with dementia .

During our inspection we found that many of the people were not able to tell us about their experiences of living at Breme Care Home. We were able to speak with six people who used the service, five family members and we received five comment cards where people gave their views about the care and treatment that people received. We observed the care of some of the people who were unable to speak with us because their dementia affected their ability to recall or communicate.

We looked at some of these people’s care records. We also spoke with seven members of staff who were working on these units, the deputy manager and the registered manager.

We saw that before people came to live at the home their health and social care needs were identified. This included information about people’s dementia care needs and what their daily routine preferences were. This was completed with people themselves as far as possible and with people’s representatives to ensure that they felt part of the person’s care.

Throughout the day of our inspection we observed staff worked hard to ensure the personal care and health needs of people were met. The interaction between staff and people who used the service were generally good. We did however observed two members of staff who supported two people who lived at the home use inappropriate techniques when they moved or repositioned these people. This practice can put people at risk of harm or injury as they were inappropriate and unsafe.

We saw that health and social care professionals were consulted with and staff worked with other providers. This made sure that people received the right care at the right time to meet their individual needs.

We found that the registered manager had systems in place to enable the quality of care to be assessed, monitored and improved.

During our inspection we spoke with seven people who lived at the home and four family members and observed daily life at the home. We also spoke with the registered manager and four members of staff.

We observed that staff treated people as individuals. There were positive interactions between staff and people with lots of laughter and smiling and clear friendships were established. It was clear from what we saw that staff knew people’s needs and provided care and support in a gentle way when people’s behaviour needed to be supported.

One person who lived at the home told us: “I like it here, the staff are very caring”. “I get up when I want, they give me lots of drinks, I go to bed when I like which is very nice”.

People’s family members told us positive things about the care and support people received whilst they lived at the home. They told us that they felt involved in any decisions that needed to be made and these were done with their relation’s best interests at heart. One family member told us: “They (staff) are always there for you” and another said: “We are involved in discussion on their care; I also make amendments to their care when needed”.

We saw there were enough staff to meet people’s care needs and promote their social opportunities. One family member told us: “They don’t just plonk them in front of a TV, the girls talk to them in a lovely way, they don’t talk at them. “The staff are very caring, they all know my name”.

We visited Breme Care Home to review the improvements they had made since our last visit in October 2011. The last visit found concerns particularly about the management of people’s skin and nutritional care needs. In response to these findings, we referred one person who used the service to safeguarding at Worcestershire County Council. Our concerns were investigated by the adult protection team and found to be true.

Following our visit the registered manager sent us a detailed improvement plan telling us what action they intended to take to make sure that people did not experience any further poor outcomes of care.

We pathway tracked the care of two people and looked at how their care was provided and managed. We saw that staff at Breme Care Home looked after these two people well and wrote down what help they had given them.

We saw that staff interacted with people who used the service in a friendly, courteous and respectful manner. Staff demonstrated they were aware of people’s care and support needs. We saw that people were neatly dressed in clean clothes and had clean hair and nails, which indicated that staff knew the importance of helping people look their best.

We found that people were receiving effective and appropriate care, treatment and support to meet their personal needs.

We looked at the quality of the information in the care records. There had been a significant improvement since our last visit in the quality of the information available in the care records for the two people whose care we tracked. The care records were individualised and overall gave care staff good information about peoples’ needs to make sure that they knew what care was needed.

We did find that some further improvements were needed to care records to protect and make sure that peoples’ safety and wellbeing was maintained at all times.

We carried out this visit as there had been a safeguarding investigation coordinated by the lead agency for safeguarding Worcestershire County Council (WCC). The investigation also involved the Police due to alleged neglect of care of an identified person. The outcome of the investigation by WCC into the neglect of care was found to be true. The home had recently told us and WCC about a person who had developed a pressure sore at the home, which with the support from the district nurse was improving. A health care professional has raised concern about the care of this person, which is currently being investigated through safeguarding.

When we visited the home we spoke with people who lived there. People told us that the care at the home was ‘very good’ and its ‘nice here’. We saw that people were neatly dressed in clean clothes and had clean hair and nails, indicating that staff knew the importance of helping people look their best. Some people that used the service at Breme had dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people had, on Mulberry unit we observed their care during breakfast time. The staff supporting the people knew what support they needed and care workers respected their wishes if people wanted to manage on their own. We saw some very positive interactions between staff and people who used the service.

We spoke to a relative of a service user who had been living at Breme for the last six years. They told us that they were very happy with the care and they had no concerns. They told us if there were ever any issues of concern, that they were addressed by the staff. They told us ‘Mum is happy here, I would know if she wasn’t’.

People told us they had a choice of food, which was ‘good’ and they ‘had plenty to eat’. They told us the staff were ‘very nice’ and were kind to them. On the morning of our visit people were playing bingo in one of the dining rooms. The hairdressing salon was in use and we saw five ladies chatting with the hairdresser and each other whilst having their hair done. Staff were also spending time with people on a one to one basis talking to them and giving them nail care. An activity co-ordinator was currently employed for 16 hours each week, but they were hoping that these hours would be increased by the owner to enable them to further develop the social care facilities provided at Breme. Activities were both planned and spontaneous and the entire staff team were involved in the provision of social care. The home was decorated with memorabilia for people to look at, touch and rummage through. The service had a room which had been converted into a ‘public house’ with a bar and alcoholic drinks were served when the room was used. Staff told us they played traditional games in the pub such as darts and cards.

We tracked the care of two people who used the service and focused on the care of their skin and nutritional needs. We found shortfalls in their care that may have placed them at risk of harm through not receiving appropriate care due to the lack of monitoring and recording of their care needs, not having a care plan for nutrition, lack of action due to the outcome of nutritional risk assessments and poor communication amongst the staff team.

Breme Residential Care Home provides accommodation and personal care for a maximum of 60 people many of whom may have a dementia related illness. The facilities within the home are arranged over three floors. When we carried out our inspection the home accommodated 56 people.

At the time of our inspection there was 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.

This unannounced inspection was carried out over two days on 16 and 17 October 2014. At our previous inspection on 6 February 2014 we identified a breach in a regulation associated with the Care and welfare of people who use services. Following the inspection the provider sent us an action plan to tell us how they intended to make improvements. We found that improvement had been made in the areas we had previously identified.

People told us that they felt safe and well cared for by the staff. We saw that staff were respectful and calm when they spoke with people. Staff had awareness and demonstrated ways that they upheld people’s privacy and dignity. They also recognised the importance of people’s appearance and respected people’s choices and views. Staff were aware of their responsibility to protect people from the risk of abuse to ensure people were safe and not at risk of harm.

Staff received training and supervision to provide them with the skills, knowledge and support to enable them to care for people who lived at the home.

People felt that at times there was not sufficient staff on duty. We saw occasions when lounges had no staff member present and we became aware that the call bell was not always answered promptly by staff on duty. Medicines, creams and ointments were not always signed for to evidence that people had received them as prescribed.

We saw that care plans and risk assessments were in place and that these were regularly reviewed and updated. Some information available to staff was conflicting about people’s care needs. People had access to medical professionals to ensure their health care needs were met. People’s social needs were met by means of a range of methods for people to engage in pastimes and interest.

The registered manager and staff were aware of the requirements around the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). These are to protect people who may not be able to make an informed choice about their care.

We received positive comments from people about the food provided at the home and about the choice available to them. We saw that staff supported people and provided assistance and encouragement in eating as necessary. Snacks and drinks were available throughout the day to ensure that people were provided with sufficient food and fluids.

Systems were in place to monitor the quality of the service provided to people. People were able to raise concerns and make comments about the service provided. These were used by the provider as a means of making service improvements. Accidents and incidents were monitored and reviewed to ensure people’s wellbeing.