The inspection of Brocklehurst Nursing Home (Brocklehurst) took place on 26, 27 and 28 November 2018. The first day was unannounced. The service was previously inspected in April 2018 and we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to need for consent, safe care and treatment and good governance. At this inspection we found significant improvements had been made and the provider was meeting the regulations.

Brocklehurst is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Brocklehurst can accommodate up to 41 people in a two-storey purpose-built building. At the time of this inspection there were 40 people living at Brocklehurst. The care home consists of four units across two floors and is set in its own grounds. Each unit has its own kitchenette used for making drinks and snacks. Each unit accommodates people needing both residential and nursing care. Both floors are accessible by two staircases, at each end of the building, and one central lift and staircase. On the ground floor, there is a large lounge and dining room, the kitchen, laundry facilities and a hairdresser’s salon.

There was a manager in post who was registered with the CQC since July 2018. 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. They were supported in the day to day operation of the home by a deputy manager and a clinical nurse lead.

In the main, Brocklehurst provided care and support that was safe. People and their relatives told us they received care and support that was safe.

There were some aspects of the medicine administration that were not safe. This meant people were potentially at risk of harm because they did not receive their medication as prescribed. The provider took appropriate steps to correct this issue before we completed our inspection.

People were supported by a consistent staff team who had all relevant pre-employment checks to ensure they were appropriate to work with vulnerable people. The provider had suitable systems in place to take action to protect people from abuse including accidents and incidents.

Risk assessments were up to date and most contained sufficient information for staff to support people in a safe way. We identified an example where this was not the case and the staff sought to rectify this during our inspection.

People were protected from the risk of infection because suitable arrangements were in place to ensure hygiene standards were maintained. The home was visibly clean and free from unpleasant smells. Staff were knowledgeable about and demonstrated good infection control practices.

People, staff and visitors to the home were protected from harm because there was a regular programme of maintenance and checks of the premises and equipment. This included lifts, hoists, fire safety equipment and the water system.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The provider had submitted appropriate applications for the deprivation of liberty safeguards to the local authority and the registered manager had a good system in place to track the progress of these.

Staff were competent and had adequate professional support to support people safely and effectively. Staff received an induction, training considered mandatory by the provider and shadowed experienced colleagues prior to working unsup

The inspection of Brocklehurst Nursing Home (Brocklehurst) took place on 17, 18 and 20 April 2018. The first day was unannounced. The service was previously inspected in January 2017 and we found breaches of the Health and Social Care Act regulations relating to need for consent, safe care and treatment and good governance. At this inspection we found some improvements had been made but not sufficient to ensure the provider was meeting the regulations.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) of safe, effective, caring, responsive and well led to at least good. They submitted an action plan in March 2017 which identified what action would be taken to address the concerns identified at the inspection in January 2017. At this inspection, we noted improvements had been made in all areas of concern identified at the last inspection such as staff recruitment, providing meaningful and appropriate activities, need for consent and records management. However further improvements were required in some of these areas, for example, need for consent and audit processes. Further information about these concerns is identified within this summary and the full report. This is the second time the service has been rated ‘Requires Improvement’ overall.

Brocklehurst is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Brocklehurst can accommodate up to 41 people in a two-storey purpose-built building. At the time of this inspection there were 33 people living there. The care home consists of four units across two floors and is set in its own grounds. Each unit has its own kitchenette used for making drinks and snacks. Each unit accommodates people needing both residential and nursing care. Both floors are accessible by two staircases, at each end of the building, and one central lift and staircase. There is a large lounge and dining room on the ground floor though most people preferred to dine in the communal area on their respective units. The kitchen and laundry facilities were situated on the ground floor as was the hairdresser’s salon.

There was a manager responsible for the day to day operation of the service. However our records showed they were still in the process of registering with the CQC. 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 three breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014 in relation to medicines management, need for consent and good governance. You can see what action we told the provider to take at the back of the full version of the report.

We found the service was not always safe in some respects though people told us they felt safe with the staff who supported them. People were supported by a consistent staff team and the provider had suitable systems in place to take action to protect people from abuse including accidents and incidents.

People were supported by competent staff to take their medicines safely. We found concerns with how medicines were stored. This could compromise the integrity of the medicines and put people at risk of harm.

Recruitment processes had improved. Staff employed at the home had undergone all appropriate pre-employment checks to help ensure they were suitable for the role. Staff we spoke with were aware of safeguarding policy and procedures and knew what action to take if they suspected abuse was taking place.

Risk

This inspection of Brocklehurst Nursing Home (Brocklehurst) took place on the 24, 25 and 27 January 2017. The first day was unannounced. The service was previously inspected in December 2015 when it was found to be in breach of regulatory requirements relating to need for consent, safe care and treatment and good governance.

Brocklehurst provides residential and nursing care for up to 41 people. The home had 35 people living there at the time of this inspection and is a large two storey detached building set in its own grounds. The home consists of four units across two floors. Each unit has its own kitchenette used for making drinks and snacks. Each unit accommodates people needing both residential and nursing support. Both floors are accessible by two staircases, at each end of the building, and one central lift and staircase. There is a large lounge and dining room on the ground floor but we found this area was infrequently used as most people preferred the communal area on their respective units. The kitchen and laundry facilities were situated on the ground floor as was the hairdresser’s salon that could be used weekly.

There was a manager responsible for the day to day operation of the service. However they had yet to register with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

During the inspection the home manager was on annual leave and our inspection was supported by one of the provider’s area managers and a registered manager from one of the provider’s other services.

We made recommendations that the provider updates policy documents in relation to medication to reflect current legislation and that the provider and home manager should review how information regarding people’s care and support is communicated to staff without compromising people’s privacy, confidentiality and dignity.

We found breaches in the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. You can see what action we have told the provider to take at the back of the full version of the report. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

People and relatives told us Brocklehurst Nursing home provided a safe environment in which to live. We noted that staff recruitment processes needed to be more robust to help ensure staff employed were suitable to work with vulnerable people.

Three out of four care records we reviewed contained relevant risk assessments which were reviewed and updated as an individual’s circumstances changed. We found these documents provided clear guidance and sufficient information for staff to support people safely and manage risk appropriately.

Medications were administered and stored safely. We pointed out that the top floor treatment room where medication was stored had a temperature over the recommended national guidance.

The service did not always demonstrate that it was working within the principles of the Mental Capacity Act 2005 (MCA) to ensure they sought the consent of people or their legally appointed representative before providing care and support. Applications under the Deprivation of Liberty Safeguards had been made. However there was no systematic way to track which applications had been made and when each required review.

Records demonstrated that people living at Brocklehurst had good access to healthcare professionals such as GPs and speech and language therapists when required. This meant that people’s healthcare needs were being met in line with their individual needs.

People and their relatives told us that the staff were pleasant and caring, and that

Brocklehurst Nursing Home is a large two storey detached building set in its own grounds. The home consists of four units across two floors. Each unit has its own kitchenette used for making drinks and snacks. Each unit accommodates people needing both residential and nursing support. Both floors are accessible by two staircases, at each end of the building, and one central lift and staircase. There is a large lounge and dining room on the ground floor but we found this was little used as most people preferred the communal area on their respective units. The kitchen and laundry facilities were situated on the ground floor as was the hairdresser’s salon that could be used weekly.

This was an unannounced inspection of Brocklehurst Nursing Home on the 15 and 16 December 2015. The home provides residential and nursing care for up to 41 people. The home had 35 people living there at the time of the inspection.

We last inspected Brocklehurst Nursing Home in June and July 2015. At that time we rated the service as Inadequate and the service was placed into special measures. This was because there were breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. The breaches were in relation to safe and effective person-centred care, privacy and dignity, need for consent, complaints, staff training, good governance and the regulation which requires services to notify the Care Quality Commission (CQC) of certain types of incidents.

The purpose of special measures is to provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. At this inspection we found there was enough improvement to take the provider out of special measures.

Prior to this inspection the provider agreed to a ‘Voluntary Undertaking’ with CQC. This meant the provider had formally agreed not to admit any new people to the home without prior written permission from CQC.

There was a manager in day to day responsibility of the service. However they had yet to register with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

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

People living at Brocklehurst Nursing Home were not always involved and consulted with on decisions about how they wished to be supported or where decisions had been made in their ‘best interests’, demonstrating their rights were protected.

People’s care records did not contain sufficient information to accurately guide staff on the care and support they required. Potential risks to people had not always been assessed and planned for ensuring people’s health and well-being was maintained.

Opportunities for on-going staff training and development were needed to help ensure people’s health and well-being is safely met by staff with the relevant knowledge and skills needed to do so.

Whilst improvements had been made to the quality monitoring system, these needed expanding upon to ensure all areas of the service were reviewed and evidenced any areas of improvement had been acted upon.

We found overall the system for managing medicines was safe. We have recommended however that the service considers current good practice guidance in relation to the administration and recording of prescribed ‘thickener’ medicines.

Opportunities for people to participate in a range of activities offering stimulation and variety to their daily routine were limited. We have made a recommendation about the type of oppo

We inspected this service on the 16 June and 6 July 2015. Both days of the inspection were unannounced. This meant the service did not know when we would be undertaking an inspection.

The home had not had an inspection since it had been with the current provider. The home was previously managed by Anchor Homes and was last inspected in March 2014. Sure Care (UK) Limited began managing the home in May 2014. This planned inspection was bought forward following concerns raised with the Care Quality Commission (CQC) about the safety of people living in the home.

Brocklehurst Nursing Home is a large two storey detached building set in its own grounds. The home provides residential and nursing care for up to 41 people. The home had 38 people living there at the time of the inspection.

The home consisted of four wings across two floors. Each wing had its own kitchenette used for drinks and snacks. Each wing accommodated people needing both residential and nursing support. Both floors were accessible by two staircases, at each end of the building, and one central lift and staircase. There was a large lounge and dining room on the ground floor but we found this was little used as most people used the communal area on their respective wings. The kitchen and laundry facilities were situated on the ground floor as was the hairdressers who could be used weekly.

The home had a new manager who stated their intention to register with the Care Quality Commission. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The new manager had been in post since April 2015, three months prior to the inspection. The service had been previously managed by the area manager since the previous manager left in January 2015.

At this inspection we found a number of breaches to the regulations as identified below.

Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 focuses on people receiving the support they need. We found the home did not use all the available information to appropriately assess and meet people’s needs. This included information from professionals and from the homes own assessments.

We also found people were not supported to be involved as much as they could be with decisions about their own care. We found family members were routinely used as the first point of contact rather than the individual themselves. We found and people told us that people’s personal hygiene needs were not being met in a timely manner.

We found the home had not taken into consideration the practicalities of meeting people’s specific support needs. This included the management of hearing aids, glasses and false teeth. This included an absence of detail as to how to review the person’s condition and ensure their support aids remained in functioning and working order.

We also found a lack of assessment and review of people’s needs, contradictions within care plans and across file information left a risk of people receiving care that was unsuitable or unsafe. This included the support people needed to prevent pressure areas and sores, and support people needed with the care of their mouths. We saw four assessments from the nursing home team for people in the home who required specific support with the care of their mouth and none of them had a care plan in place to deliver this.

We found this to be a breach of Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We found the people who lived in Brocklehurst were not treated with dignity and respect. We found staff acted without due care and diligence about people’s feelings. Staff appeared too busy to be concerned about the things that would separate basic care from good care. This included asking people for their thoughts on their own care.

We also found the lack of regard for people’s personal possessions and toiletries showed staff did not pay attention to people’s choices around what they wanted to use or not.

We found this to be a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Throughout the day we observed when staff communicated with people, it was often to instruct them as to what they were to do next. This included telling people they were now moving to lounge for the day or going back to their room for a rest. Within people’s files there was a lack of evidence of formal consent. We noted a number of consent documents but these were mainly not signed. There was confusion within the files we looked at to ascertain if people were able to give their own consent or if suitable people had been appointed to support them in making decisions. There was a lack of appropriate and legal consent

We found this was a breach of Regulation 11 Health and Social Care Act (Regulated Activities) Regulations 2014.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 focuses on the safety of people living in the home. We found a number of areas of concern under this regulation. We found the home did not have specific policies and procedures for managing medicines including receiving and destroying stock. The home had a complex system for administering medicines from two different pharmacies. A number of errors had been picked up prior to the inspection and there had been minimal action taken to improve the situation. We found people were not receiving their medicines on time which may have impacted on their health and wellbeing. Staff had not received any training on medicines for some time and some were not confident in the home’s system as they continued to find errors.

We also found there was not an overall health and safety audit for the building and the people who lived within it. We found doors to stairwells were accessible to all, leaving a potential risk to people who required support with their mobility. None of the risks associated with the building and the people who lived there had been assessed.

We found when people had been assessed as requiring additional support it was not always provided. Staff were not delivering care in a safe way to people who lived in the home as they were not delivering care to minimise assessed risks. This was because when risks had been assessed appropriately, risk management plans and strategies were not being identified or implemented to best meet the needs of the people in the home.

We found the home did not have suitable plans in place to manage major incidents. This included a lack of specific planning to support the people who lived in the home and a lack of contingency planning if the home became uninhabitable.

When reviewing staff records and from speaking to staff it was clear they had not received the ongoing training and support they required to ensure their competence in specific clinical roles. We found care staff were expected to ensure people received their medicines had had no medicines training. The lack of support, supervision, training and professional competency testing of the clinical team had led to avoidable mistakes.

We found this was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

During the inspection we also found the home had not safeguarded people who lived there against potential acts of abuse due to a lack of effective systems to prevent and recognise abuse. This included acts of neglect and illegal restraint. Over the course of the inspection the CQC raised six safeguarding alerts to be investigated by the local authority to ensure people were safe and protected.

We found this was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We found the provider was not meeting the nutrition and hydration needs of the people living in the home. Where risks were identified the service was not acting to reduce the risks to people and thus not ensuring their health and wellbeing was maintained. We found records used to support people were inaccurately completed and referrals to specialist support were not always made.

We found this was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

The home had an activity co-ordinator told us they were unable to develop the role as they would like as there was not enough time to do this.

The manager told us they did not have any records of any complaints made prior to them starting in post in April 2015. The CQC was however aware of two ongoing complaints that had progressed to safeguarding. The provider didn’t record any issues/concerns/complaints received or what action was taken as a result.

We found this was a breach of Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 focuses on how the home ensures the service is meeting the needs of people living there and looks at ways at improving service provision. We would expect this to be done by the home with the provider monitoring and auditing provision to ensure it meets the regulations outlined under the Health and Social Care Act. We would also expect them to be regularly sourcing feedback from people in the home and other interested parties to ensure they are meeting their needs. We found a number of areas of concern under this regulation.

We also found a lack of complete records for decisions taken and reached in relation to the care and treatment provided to people. This included procedures not being followed in line with the Mental Capacity Act 2005 to ensure people were supported lawfully and where they could make decisions around their own care they were allowed to do so.

A lack of monitoring and audits meant the manager had no information upon which they could seek to drive improvements. The quality of the service could not be measured. We found a number of acts of omission that could have led to people being at risk. These omissions would have been highlighted if the provider had monitoring in place

The provider was not seeking feedback from the people who used the service, their family members, other professionals or the staff who worked in the home. As a consequence they did not know how the service was perceived by those using it, commissioning and supporting it and from those who worked in it.

The above showed us that systems and processes had not been established and operated effectively to assess, monitor and improve the quality and safety of support provided to people that lived in the home. The home had no way to ensure they were meeting the regulations of the Health and Social Care Act.

We found this was a breach of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found the kitchen and laundry were well managed. There were systems in place for appropriate risk assessment, cleaning and audit.

Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 focuses on ensuring the home has enough suitably qualified and trained staff to meet the needs of the people living in the home. We found the home were not assessing the needs of the people within it to determine the staffing levels required to support them. We found when circumstances changed staffing did not change to reflect this. On the day of the inspection staff numbers were not proportionate to people’s needs. We saw people waiting for a long time to have their call bell answered and staff waiting for a second member of staff to enable people to be moved safely.

Staff had received minimal training and formal support since the current provider had taken over the home in May 2014. New staff had not received an induction and staff had not received an appraisal by the time of the inspection. There was a lack of formal support and training for staff to confidently complete their role.

We found this was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Upon reviewing the information within the home. It was clear the Care Quality Commission had not been informed of all information required under the provider’s registration. This included notifications for allegations of suspected abuse including omissions of care and potential neglect. We had received information directly from the local Authority and not from the home via a notification.

We found this was a breach of Regulation 18 of the Health and social Care Act (Registration) Regulations 2009

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.