We carried out an unannounced inspection of Brewster house on the 13 March 2018. Brewster house 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 service accommodates up to 71 people across two floors, each of which have separate adapted facilities for people who may or may not be living with dementia. At the time of our visit, 63 people were residing at the home.

A long-standing registered manager was in place. 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.

Brewster house has been inspected at yearly intervals over a three-year period due to it requiring improvement in a number of areas. During this inspection we found that the management and staff team had worked hard to continue making improvements at the service and that these had been maintained. We did find some areas that continued to require some improvement, and have made recommendations throughout the report to support the service in these areas. Where we did find areas that required improvement, the management team were able to demonstrate that they had also identified these areas and were working on how to improve. Consequently, we found that Brewster house has achieved a good overall rating.

Medicines had not previously been managed robustly. The deputy manager had made this a focus for improvement and we saw excellent processes were in place following best practice for managing medicines in care homes.

Staff had a good understanding of safeguarding vulnerable adults, felt confident, and supported to raise concerns to team leaders and managers at the service. However, on review of some complaints we identified certain incidents, which could have been investigated as a safeguard but had not been reported to the commission or local authority. We have made a recommendation for the service to improve in this area.

People's personal information was not always stored safely in line with the Data Protection Act, 1998.

Whilst the service had appropriate infection control processes in place, protective equipment for staff and safe disposable of waste, we did observe that bathroom areas of the home were not always clean. We have made a recommendation in regards to this.

Safe recruitment practices were in place and staff were provided with a robust induction and probationary period to prepare them for the role.

The management team accessed a variety of different training opportunities for staff that met with people’s changing needs. The service had good access to other health and social care professionals to support staff to care for people.

People told us that they enjoyed the food provided at the service and had plenty of choice. When people had additional requirement’s these were met. For those with a risk of poor nutrition and dehydration, specialist advice had been sought and care plans interventions were in place to manage these risks.

Staff demonstrated caring responses to people and people told us staff and managers where kind. Relatives told us they observed staff being kind and we observed some positive interactions between people and staff during every day routines and activities.

People were not always involved in running the service and but where possible were engaged in developing their care plans. The management team were able to demonstrate plans being developed to improve people’s involvement in how the service ran, including recruitment of new staff.

The management team were passionate about continuing to make improvements at the service and had worked hard t

Brewster House is registered to provide accommodation with personal care for up to 70 older people, including care and support for people living with dementia. There were 57 people living in the service when we inspected on 23 November 2016, plus an additional four staying for short-term re-ablement. This was an unannounced inspection.

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.

Overall people were provided with their medicines when they needed them and in a safe manner. However additional work was needed in relation to the secure storage of medicines and ensuring people received their medicines when they lacked the mental capacity to decide for themselves that it was in their best interests to take them.

People received person centred care from staff who generally had a good knowledge and understanding of each person, about their life and what mattered to them. Additional training in specific health conditions would further strengthen staff’s understanding of people’s support needs.

People were supported to maintain good health and had access to appropriate services which ensured they received ongoing healthcare support. Referrals for specialist advice had not always happened promptly which meant a delay in people receiving the support they needed.

There were sufficient numbers of staff to meet people’s needs and recruitment processes checked the suitability of staff to work in the service.

There was a positive, open and inclusive culture in the service. The ethos of care was person-centred and valued each person as an individual. People were consistently treated with kindness, dignity, respect and understanding. People were empowered to have choice, independence and control in their daily lives.

People presented as relaxed and at ease in their surroundings and told us that they felt safe. Staff knew how to minimise risks and provide people with safe care. Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. People knew how to raise concerns and were confident that any concerns would be listened and responded to appropriately.

Care plans reflected the care and support that each person required and preferred to meet their assessed needs, promote their health and wellbeing and enhance their quality of life.

Staff understood the importance of gaining people’s consent to the support they were providing. The management team and staff understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

There was a person centred, open and inclusive culture in the service. The service had a quality assurance system in place which was used to identify shortfalls and to drive continuous improvement. The management team were open and responsive to issues we raised and immediately began work on making changes as a result.

At our last inspection 11 June 2014 we had concerns in relation to staffing levels and people not being treated with dignity and respect. We asked the provider to send us an action plan telling us how they intended to address the shortcomings. They sent us a report on 7 July 2014 telling us what they would do to make the required improvements. The purpose of this follow up inspection was to check if improvements had been made.

During our visit, we spoke to 11 people who used the service and two relatives. We also spoke with the manager, regional care director and 13 staff. We carried out observations which included interaction between staff and people who used the service and their mealtime experience. We looked at people's care and support records and records relating to staffing levels.

Brewster House provided a service for 70 people at the time of our inspection. Some people who used the service were not able to tell us verbally about their views and experiences so we used observation and interaction to gain an understanding of their care and support.

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?

People were protected from harm because the staff were following the correct procedures in caring for people. People who used the service were kept safe because there were enough staff on duty during the day and the night to care for them safely.

Is the service effective?

People's care and health needs had been reviewed to ensure that their needs were met by sufficient staff. Systems were being put in place such as ‘protected mealtimes’ to make the service more effective in meeting people’s needs. Whilst we found there were enough staff on the day of this inspection, further action was required to ensure that the allocation of staff resources across the service met people's needs effectively at all times.

Is the service caring?

Most of the staff had a good knowledge of people's likes and dislikes, their everyday needs and their personalities.

We saw that most staff interacted and engaged with people who used the service. Staff were caring, respectful and considerate. However, further improvements were needed in the way some of the staff communicated with people who used the service to ensure people were cared for with dignity and respect.

Is the service responsive?

Regular checks on the health and personal care needs of people who used the service were being undertaken. There were sufficient staff on duty to respond to people's needs. However, people’s needs were not always responded to in an appropriate and prompt way.

The service had employed an activities coordinator who offered a range of activities for people to enjoy.

Is the service well-led?

The provider had made improvements to the service since our last inspection. Staff felt more involved in helping to make the improvements. The provider had put systems in place to ensure that sufficient staff were on duty to meet people’s needs, with specific staff training and development in areas such as dignity and respect.

At our last inspection on 19 March 2014 we had minor concerns about the staffing levels at Brewster House. Concerns we identified included people who used the service being left for periods of time unsupervised, staff caring for people alone when two were required and insufficient staff to assist people with eating at mealtimes.

We asked the provider to respond with an action plan telling us what they would do to achieve compliance. We received their action plan on 12 May 2014 which outlined the improvements they would make and the timescales.

The purpose of this inspection was to check if improvements had been made.

During our inspection we spoke with 15 people who used the service and two relatives. We also spoke with the manager, deputy manager and regional manager and ten staff. We looked at the care and support records for 11 people who used the service and records relating to staffing levels .

Brewster House provided a service for 70 people at the time of our inspection. Some people who used the service were not able to tell us verbally about their views and experiences so we used observation and interaction to gain an understanding of their care and support.

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?

People were not protected from harm because staff were not following the correct procedures in caring for people.

People who used the service were put at risk of harm because there were not enough staff on duty during the day and the night to care for them safely.

Is the service effective?

People's assessments showed that their care and support was planned. However, their care and support was not delivered in a way that met their needs effectively.

Some people’s care and support was not individualised and did not enhance their dignity, wellbeing and independence.

Is the service caring?

Most of the staff had a good knowledge of people's likes and dislikes, their everyday needs and their personalities.

We saw positive interaction between staff and people who used the service. Most of the staff spoke with people in a caring, respectful, considerate and encouraging way. However, we saw that some staff did not treat people with dignity and respect.

Is the service responsive?

Regular checks on the needs of people who used the service were not being undertaken as identified in their care plans as there were not sufficient staff on duty to respond to people's needs appropriately.

The service did not offer a range of activities for people to enjoy. There was very little to do during the day or evening.

Is the service well-led?

The provider had told us that staffing numbers had been considered and changes implemented. However, the provider had failed to consider people’s dignity and respect when determining staffing numbers. People’s needs were not being put first because there was not enough staff who were able to support them appropriately.

The service was not well led as it was continually failing to meet people’s needs effectively and safely.

During our inspection on 19 March 2014 we discussed with the management at Brewster House information of concern with regards to staffing levels. We spent time talking with people who used the service and staff and observed them undertaking their duties. We looked at rotas and related documents and found that on many occasions there were insufficient staff on duty to care for the needs of people using the service.

We gathered evidence of people’s experiences of the service by talking with people, their relatives and staff. We observed how people spent their time and noted how they interacted with other people living in the home and with staff. We saw that people smiled and chatted with staff.

People who lived at Brewster House and their families told us that they received good care, were provided with nice food and had a comfortable room. We saw that people had care plans and risk assessments in place and were assisted in a respectful and encouraging way with daily tasks. One person said: “There’s always something nice here to eat.” Another person said: “I think they are trying to make me fat with what they give me.”

We saw that staff were recruited, supported and trained in order to care for people in a safe and caring way. Records were securely stored and maintained to ensure that people's changing needs were met in the correct way. There were systems in place to monitor people's health and wellbeing.

People who lived at Brewster House had a range of complex needs including needs associated with dementia. People who were able to speak with us told us that they felt cared for, were given choices about every day activities and encouraged to be as independent as possible. One person said “I am very content to be honest with you, which I know is a big thing at my age. I don’t think it could be any better here. Everything is done with great kindness.”

A number of people were not able to tell us directly about their experiences but we observed that they were relaxed and they interacted positively in different ways with the staff. Life history books, memory boards and memory boxes were used to help people communicate their wishes and feelings.

Brewster House had all the necessary policy and procedures, records, quality assurance and monitoring systems in place for the protection of people who used the service. Staff were well trained and supported by the manager and deputy so that they could carry out their caring responsibilities effectively. People who used the service and their families were involved in their care and their lifestyles respected. Creative practices were in place to provide a better quality of life for people with dementia.

The inspection took place on the 09 and 10 April 2015 and was unannounced. Brewster House provides care and accommodation for up to 70 older people some of whom have dementia. There was a total of 66 people living at the service at the time of our inspection.

The service has 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.

At the last inspection in August 2014, we identified two breaches of the legal requirements. We asked the provider to make improvements as there were not enough staff to meet peoples needs and their dignity was not always promoted.

The provider sent us an action plan setting out what they were going to do, and during this inspection we found that improvements had been made. There were sufficient numbers of staff on duty to meet peoples needs and staff were more aware of issues around dignity and respect.

The Provider had robust systems in place to ensure that the staff they recruited were properly vetted. Staff were clear about what abuse was and the processes to follow to protect people if they had concerns. Staff had good access to training, however their learning was not always put into practice.

Medicines were managed safely, however where people were prescribed medicine on an ‘as required’ basis this was not always offered. Risks to people using the service were assessed however were not always managed in a proactive way

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals.

People received a varied choice of nutritional meals, however where assistance to eat was required, this was not always efficiently provided. There was a range of activities available for people to participate in , however those suitable for people living with dementia were very limited.

Most staff were very caring and had good relationships with the people living in the service.

People had their care needs assessed and this included a social history and details of their care preferences. However some care delivery was task led and did not reflect a person centred approach.

Complaints were taken seriously by the provider and there was documentation in place to show that concerns had been investigated and clear actions taken where short falls had been identified.

The provider had a clear management structure in place, and the manager was accessible and visible. Quality assurance and governance systems were in place and a range of audits were undertaken, some of which were very comprehensive. However this was not consistent. There was a lack of management oversight in some areas and analysis of risk undertaken, was not always in sufficient depth.

During the inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) as staff were not following safe moving and handling procedures. You can see what action we told the provider to take at the back of the full version of the report.