The inspection took place on 19 June 2018 and was unannounced.

Brentwood Care Centre is a ‘care home’. 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 care home accommodates 112 people in one building, over three floors in four separate units including a nursing unit on the top floor. At the time of our inspection there were 74 people living at the service some of whom were living with dementia.

There was 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.

At the last inspection the service was rated as requires improvement with a breach of Regulation 12; safe care and treatment as medicines were not always managed safely. Despite improvements in some areas which meant the service was no longer in breach of the regulations the rating remains requires improvement.

Improvements had been made to the safe management of medicines and staff supported people to take their medicines as prescribed. However, further improvements were required to ensure people received their covert medicines in accordance with prescriber’s guidance. The provider had policies and procedures in place designed to protect people from abuse and staff had received training in how to safeguard people from the risk of abuse.

Risk assessments and management plans were in place to reduce risks to people’s health and safety but care records had not always been updated to reflect the current risks to people. Appropriate recruitment procedures were in place and on the day of inspection people’s needs were met by sufficient numbers of staff. However, mixed views were expressed by staff, people and professionals regarding staffing levels.

The environment was safely maintained and good infection control practices were adhered to. People reported satisfaction with the level of cleanliness and hygiene. Accidents and incidents were recorded and learned from with measures put in place to minimise the risk of re-occurrence.

Staff had received training and supervision to ensure their competence in their role, however annual appraisals of their practice had not been completed to support continuous learning and development.

Record keeping was not always robust, particularly on the nursing unit, which meant we could not be sure people always received effective care and support to maintain their health and wellbeing. People were supported to access healthcare professionals but improvements were required to ensure timely referrals were consistently made. People were supported to have enough to eat and drink and were offered choices, however improvements in monitoring food and fluid intake were required.

People were supported to make their own decisions and choices. The environment was suitable to meet the needs of people living with dementia.

Staff developed caring relationships with people and supported them to express their views and be involved in making daily decisions about their care and support. Independence was promoted and people’s privacy and dignity was respected.

People received personalised care that was responsive to their needs and enjoyed a range of activities, which were tailored to their interests and choices. People and their relatives had access to the complaints procedure. People were consulted about their end of life care choices and wishes.

Quality assurance mechanisms were in place to monitor and improve the safety and quality of the service. Staff felt supported by the management team and there was good morale and a strong sense of teamwork.

People,

We previously carried out an unannounced focussed inspection on 5th May 2016 in response to information of concern we received about whether people were receiving safe care and treatment at the service, specifically on the nursing unit. Areas of concern included how risk was managed, medicine management, information sharing, insufficient staffing levels and staff competencies.

During the previous inspection which focussed on the nursing unit and looked at the domains of safe and well-led we found three separate breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the safe management of medicines, risk management, staffing and the way in which the quality and safety of staff and the service was monitored.

Following the focussed inspection, the provider provided us with an action plan, which set out what they would do to meet the legal requirements in relation to the breaches and to improve the service. Because the breaches potentially affected all areas of the service we undertook a comprehensive inspection looking at all domains across all five units to check that the service had implemented their action plan and to confirm that they now met the legal requirements.

This inspection took place on 30th March 2017 with a follow up visit on 4th April 2017 and was unannounced. Brentwood Care Centre provides accommodation over two floors on five separate units for up to 112 people who require nursing or personal care. There were 83 people living at the service at the time of our inspection.

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.

At this inspection we found that the service had followed its action plan to address the breaches and those aspects of the service we had identified that required improvement which meant that the nursing unit now met the legal requirements and was no longer in breach of the regulations. However, this inspection looked not only at the nursing unit but also at the service as a whole and in so doing found a continued breach of Regulation 12 (1) (g) safe and proper management of medicines.

On two of the five units we found that people's medicines were not managed safely.

There were systems and processes in place to monitor the quality and safety of the service, however these were not always effective as we found medicine audits had failed to identify areas that required improvement to ensure people's safety. We recommend that the service re-evaluate its current system of auditing medication.

There were sufficient numbers of appropriately trained staff who had been recruited safely and were aware of their safeguarding responsibilities and knew how to protect people from risk of harm.

Staff knew people well and were aware of their preferences so were able to provide person centred care.

Training, supervision and support was made available to staff which provided a method of assessing staff competency and promoting learning and development.

Where appropriate mental capacity assessments had been completed. This ensured that any decisions taken on behalf of people were in accordance with the Mental Capacity Act (MCA), 2005.

People were involved in making decisions about the care and support they received. Where people experienced difficulties with decision-making, they were supported by staff who were aware of their responsibilities under the legislation.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS ) and made appropriate applications when necessary.

People were supported to maintain their health and had access to wide range of healthcare professionals.

A choice

We carried out an unannounced comprehensive inspection of this service on 3 December 2015. Following on from that inspection we received concerns in relation to the safe care and treatment of people and the managerial oversight of the service. As a result we undertook a focused inspection on 9th May 2016 to look into those concerns. This report only covers our findings in relation to those topics at that time. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Brentwood Care Centre on our website at www.cqc.org.uk.

Brentwood Care Centre is a nursing home registered to provide accommodation, personal and nursing care to 112 people. On the day of our inspection 82 people were using the service, living in four separate units including a dementia unit and a nursing unit.

During the inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the safe management of medicines, risk management, staffing, and the way in which the quality and safety of the service was monitored. You can see what action we told the provider to take at the back of the full version of the report.

There was a registered manager in post at the time of inspection though since our visit a new manager has been appointed. 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.

At the time of inspection we found that risks to people were not consistently well managed. Assessments were not always up to date and did not hold sufficient detail to monitor and analyse people’s health and wellbeing to keep them safe.

The management of medicines was not consistently safe. Records were not completed accurately and there were incidents where staff had not adhered to the medicine policy and procedure regarding administration of medicines.

There were insufficient numbers of staff to keep people safe and a lack of managerial oversight which meant that the skills and competency levels of staff had not been consistently monitored and assessed.

Record keeping was not of an adequate standard and there were ineffective systems in place to monitor quality and drive improvement.

The registered manager was open and transparent and responded promptly to our requests for information. However they did not always provide us with statutory notifications in a timely fashion, nor was the information received always accurate.

The manager was well-thought of by staff and took a hands-on approach. They were able to demonstrate how they used accidents and incidents as opportunities for staff learning and development.

Safe recruitment practices were followed.

After our inspection the Provider informed us that they had appointed a new registered manager. The provider acknowledged the failings of the service identified during our inspection and prior to receiving a copy of our report were pro-active in providing us with their own action plan which identified many of the same concerns that we had found and set out how the areas requiring improvement would be addressed.

The inspection took place on 3 December 2015 and was unannounced.

Brentwood Care Centre provides accommodation and personal care for up to 112 older people and people who may be living with dementia. The service does not provide nursing care. At the time of our inspection there were 99 people using the service.

There was a registered manager in post at the service. 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 were safe because the management team and staff understood their responsibilities in managing risk and identifying abuse. People received safe care that met their assessed needs.

There were sufficient staff who had been recruited safely and who had the skills and knowledge to provide care and support in ways that people preferred.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely.

People’s health and social needs were managed effectively with input from relevant health care professionals and people had sufficient food and drink that met their individual needs.

The adaptations and design of the premises met people’s needs and promoted their independence but improvements needed to continue to the decoration of the premises.

The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) which apply to care homes. We found the provider was following the MCA code of practice.

People were treated with kindness and respect by staff who knew them well.

Staff respected people’s choices and took their preferences into account when providing support. People were encouraged to enjoy pastimes and interests of their choice and were supported to maintain relationships with friends and family so that they were not socially isolated.

The management team encouraged and supported staff to provide care that was centred on the individual.

The provider had systems in place to check the quality of the service and take the views and concerns of people and their relatives into account to make improvements to the service.

People’s privacy, dignity and independence was not always respected and people’s views and experiences were not always taken into account in the way care was provided. “I do think that [relative] should be told about [their] own health, before information is passed onto me, [they] may be frail but [they are] perfectly able to understand, and want to be more involved in [their] care.”

People had not always been asked for their consent and therefore the provider did not always act in accordance with their wishes.

People did not always experience care, treatment and support that met their needs and protected their rights. We also found that people were not always involved in planning their care and support.

We found that people who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff were aware of what abuse was and how to report this and the manager acted appropriately when this was highlighted.

We observed and people told us that there were not enough staff to meet people’s needs and provide consistent and safe care to people. One person who used the service told us, "The night staff will start about 5am to get people up. I see them across the hall waking them up. If a person has dementia then they are not necessarily going to object to the time.”

Staff were not always supported to deliver safe and effective care to people.

On our inspection of 14 January 2013, we found significant improvements across all areas, except safeguarding where we still have concerns. However we saw that the provider has a newly appointed manager in post.

Due to the complex needs of some of the people who use the service, we used a variety of methods to help us understand the experiences of people living at the home.

We saw that people’s needs were assessed and delivered in line with their care plan and that people were provided with a choice of suitable and nutritious food and drink. People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on.

We found that the service did not safeguard people from abuse as the provider had failed to respond appropriately to an allegation of abuse made by a person who used the service.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The provider had taken steps to provide care in an environment that is suitably designed and adequately maintained. The home was clean and hygienic.

Appropriate checks were undertaken before staff began work within the home. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We found that people were not fully involved in the review of their care. Where they were people told us they were not confident that their views were listened to. One relative told us they were given insufficient time to look at the review of care to enable them to comment.

Care plans were incomplete and were not up to date. Not all staff who were designated to access the computerised care plans had received training to enable them to use them efficiently. People were referred for advice and support from health and social care professionals. However care staff did not rigorously follow the plans that had been set by speech and language therapists (SALT) and dieticians. This placed people at risk of not having their nutritional needs met.

There was no evidence that consent to administer medication had been obtained. People told us that staff did not always follow the treatment plan. Medication records were not audited. In one instance a person was non-compliant with medication but no action had been taken to refer to the GP.

There had been nine safeguarding alerts raised of which none had been raised by care home staff or management. Safeguarding policy and procedures were in place but these were not followed. There was an ongoing training programme in place, however training in safeguarding adults was not provided for new staff.

People told us that the standard of cleaning of the premises had improved considerably and this was confirmed from our observations. Additional domestic staff were now employed to work in the evenings.

The provider had taken measures to provide temporary management support until a new manager and regional manager were in post. Some action had been taken to address concerns but further and sustained improvements were required.

Relevant checks had been obtained prior to appointment of new staff. However we found one person currently employed who had serious offences on their Criminal Records Bureau check (CRB). This did not appear to have been considered during the recruitment process. We brought this to the attention of the provider and prompt action was taken to suspend the person and instigate an investigation.

We found that staffing levels were sufficient to meet people’s needs. However people were concerned at the changes in management and staff and the high use of agency staff. A recruitment drive was underway and additional staff had been employed until new staff were in post.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke with the relatives of five people living at Brentwood Care Centre.

We received concerns that people were not able to have a shower due to a lack of staff. We spoke with a number of people living at the home who all told us that they liked living at the home and felt well cared for. One person said that they had a shower every week and that was enough for them. A relative told us "They give X a wash and change X every day.“

Two relatives raised concerns about the quality of the food provided. However people living at the home told us that the standard of food provided was good. One person told us “The food is nice. ‘I could have a ‘fry up’, but I don’t want it.” Another person told us “The food is very good. For supper they do a sandwich with whatever filling you like and a piece of cake.”

Three relatives raised concerns about the standard of cleaning and the numbers of care staff on duty. One person told us “They look after them alright but there are not enough of them.” Another person told us “The staff are extremely good but there are not enough of them.

Relatives of people living in Brentwood Care Centre with whom we spoke praised the staff for the kind and respectful way they spoke to people.

Relatives of people living in Brentwood Care Centre with whom we spoke said they felt their relatives were being well cared for even though they felt there were not always enough staff available to meet peoples’ needs at peak times.

Relatives of people living in Brentwood Care Centre with whom we spoke made positive comments about the food provided at the home. One person told us they were concerned that their relative never had a jug of water available to them.

We carried out this inspection to follow up on our previous findings of non-compliance from our inspection on 25 October and 22 November 2013. We found the provider had made the necessary changes.

We considered all the evidence we had gathered under the outcomes we had inspected 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People who used the service had risk assessments in place to enable them to be as independent as possible.

People had received Mental Capacity Assessments (MCAs) in respect of day to day decisions. This meant that where possible they were involved in decisions about their lives. Where it was deemed they could not make decisions the staff and other people acting on their behalf were involved.

We found there were enough staff on duty to support people safely and to meet their needs appropriately.

Is the service effective?

People were involved in the planning and review of their care plans and had signed to consent to this.

Menus were available in a pictorial format to aid understanding for those people who needed this type of assistance.

Staff had received appropriate training to enable them to carry out their roles effectively.

Is the service caring?

People were treated with dignity and respect by staff, who were responsive to their needs.

We observed positive interactions between staff and people who used the service. One person told us, “I like to be up about 5am, and I do not like to go to bed until about 11pm as my joints get very painful in bed. I need to be hoisted, so am grateful that staff do not tell me when to go to bed, or get up.”

Is the service responsive?

People’s care plans were written in a person centred style, and were reviewed and updated regularly.

People were assisted to enjoy a range of activities, with support when required.

Is the service well led?

The service did not have a registered manager. However, recently a new manager had been employed, in an interim position.

Quality assurance procedures were in place, however, they had not been in place long enough to prove sustainability.