This inspection took place on 10 and 11 April 2018 and was unannounced. Brook House is a ‘care home’ with nursing. People in care homes receive accommodation and nursing or personal care as a 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.

The home is owned and operated by Barchester Healthcare Homes Limited. Brook House is registered to provide care and accommodation for up to 47 people. At the time of the inspection there were 45 people living in the home.

At our last inspection on 4 April 2016 the home met regulations inspected and was rated good. The home remained good at this inspection.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 who lived in the home and their relatives told us they were satisfied with the care provided in the home and spoke positively about care staff and management at the home. Some people in the home had complex needs and were therefore unable to provide us with feedback. We therefore spent time observing interaction between people and staff. During the inspection we observed people were well cared for and appeared relaxed and comfortable in the presence of care staff. We observed positive engagement between staff and people. Staff were respectful of people and showed a good understanding of each person’s needs and abilities.

Risks to people had been assessed, updated and regularly reviewed to ensure people were safe and risks to people in relation to treatment or care were minimised.

People we spoke with told us they felt safe in the home and around staff and this was confirmed by relatives we spoke with. Staff had received training on how to identify abuse and understood their responsibilities in relation to safeguarding people, including reporting concerns relating to people’s safety and well-being.

Skin integrity was effectively managed by the home. We saw good evidence of diligent skincare and clear guidance was detailed in care plans. Pressure sore repositioning charts were well maintained for people at high risk of developing pressure ulcers.

Medicines were managed safely and staff were appropriately trained. We however found that there was no provision to dispose of unwanted cytotoxic medicines [medicines that have a toxic effect on cells] at the home and made a recommendation in respect of this.

We discussed staffing levels with management and they advised that staffing levels were assessed depending on people's needs and occupancy levels. The home used their own dependency tool to monitor this. The majority of staff we spoke with told us there were sufficient numbers of staff to safely meet people’s individual care needs. During the inspection, we observed staff did not appear to be rushed and were able to complete their tasks.

The home had appropriate fire and emergency systems in place. There was a record of essential maintenance carried out and this was monitored and maintained by the home's maintenance manager.

Staff received on-going training and spoke positively about the training they received. Regular supervisions and appraisals ensured staff performance was monitored.

All staff we spoke with told us they were well supported by management at the home and said that morale in the home was positive.

People received a comprehensive initial assessment of their needs with their families’ involvement before moving into the home. The pre-admission assessment included information about people’s health and care needs. Individualised care support plans were then prep

This inspection took place on 4 April 20016 and was unannounced. Brook House is a care home with nursing. The home is owned and operated by Barchester Healthcare Homes Limited. Brook House is registered to provide care and accommodation for up to 47 people.

At our last inspection on 6 August 2014 the service met the regulations inspected.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and their relatives informed us that they were satisfied with the care and services provided. On the day of our inspection we observed that people were well cared for and appropriately dressed. People who used the service said that they felt safe in the home and around staff. Relatives of people who used the service and care professionals we spoke with told us that they were confident that people were safe in the home.

Systems and processes were in place to help protect people from the risk of harm and staff demonstrated that they were aware of these. Staff had received training in safeguarding adults and knew how to recognise and report any concerns or allegations of abuse. Comprehensive risk assessments had been carried out and staff were aware of potential risks to people and how to protect people from harm.

People’s care needs and potential risks to them were assessed. Staff prepared appropriate care plans to ensure that that people received safe and appropriate care. Their healthcare needs were closely monitored and attended to. Staff were caring and knowledgeable regarding the individual choices and preferences of people.

On the day of the inspection we observed that there were sufficient numbers of staff to meet people’s individual care needs. Staff did not appear to be rushed and were able to complete their tasks. However some staff we spoke with told us that the staffing levels were inadequate and extra staff were needed as they were sometimes very busy. We raised this with management and they informed us that staffing levels were regularly reviewed depending on people's needs and occupancy levels.

Systems were in place to make sure people received their medicines safely. Arrangements were in place for the recording of medicines received into the home and for their storage, administration and disposal.

We found the premises were clean and tidy and there were no unpleasant odours. There was a record of essential inspections and maintenance carried out. The service had an Infection control policy and measures were in place for infection control.

Staff had been carefully recruited and provided with induction and training to enable them to care effectively for people. They had the necessary support, supervision and appraisals from management.

People’s health and social care needs had been appropriately assessed. Care plans were person-centred, detailed and specific to each person and their needs. Care preferences were documented and staff we spoke with were aware of people’s likes and dislikes. Identified risks associated with people’s care had been assessed and plans were in place to minimise the potential risks to people. People told us that they received care, support and treatment when they required it. Care plans were reviewed monthly and were updated when people’s needs changed.

Staff we spoke with had an understanding of the principles of the Mental Capacity Act (MCA 2005). Capacity to make specific decisions was recorded in people’s care plans.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS ensure that an individual being deprived of their liberty is monitored

A single inspector carried out this inspection. We spoke with nine people who used the service, three relatives and three members of staff as well as the registered manager. We reviewed the care records in place and looked at how the service was managed in relation to the standards we inspected.

The focus of the inspection was to gather evidence to answer the five key questions : is the service safe, effective, caring, responsive and well-led?

Is the service safe?

The service was safe because risks were identified and managed effectively. There was adequate monitoring in place to ensure people's needs were fully met, for example in relation to hydration and nutrition. There was a strong focus on meeting the individual needs of people who used the service and this helped to reduce any particular risks to which they might be exposed.

The premises were well maintained and efforts had been made to reduce any environmental risks as far as reasonably possible.

Equipment was regularly maintained and serviced so that people were not at risk from using faulty, unsafe or unsuitable equipment. The environment was suitably clean and arrangements were in place to minimise potential infections arising.

The service had thought about planning for foreseeable emergencies and this had resulted in comprehensive plans and actions to cover any such occurrences.

The service had effective measures and procedures in place to ensure infections were controlled.

Is the service effective?

The service had sought people's consent before providing their care and support.

We were told by people who used the service and their relatives the registered manager and staff worked hard to provide a high standard of care and support at all times.

We were told the registered manager engaged very well with relatives and responded effectively to any concerns raised. We observed people had in place the equipment to ensure they received the care and support they required.

Is the service caring?

The service was caring because people who used the service and relatives told us the registered manager spent lots of time with people who used the service and demonstrated a very caring approach towards ensuring people were well cared for and happy.

We observed staff interacting with people and saw people were treated with respect which ensured their dignity was maintained. The service worked hard to ensure people's holistic needs were met, for example by ensuring people were supported to attend local churches of their choice. Reasonable adjustments were made to ensure people's dietary choices were respected and action had been taken with regard to the provision and quality of food available following a person's relative raising an issue about this.

Is the service responsive?

The service was responsive because we were told complaints made were listened to and we saw action was taken to resolve them as fully as possible. The service worked well with local hospitals to ensure people who were returning home were well supported to adjust to the change of environment.

The service focused on meeting people's needs as they changed over time. For example, people whose mobility had decreased were provided with appropriate equipment to ensure they could be safely supported by staff to move and transfer.

Is the service well-led?

The registered manager had ensured there were systems in place to assess and monitor the quality of service being provided. They showed us evidence of the fact they used such systems carefully to continually assess quality and they acted upon issues which the regular audits they had undertaken highlighted as needing action.

The registered manager had made sure there were robust systems in place to ensure all necessary checks were undertaken prior to staff being employed at the service and they monitored these systems to ensure this remained the case.

We carried out this inspection to check if the provider had complied with a compliance action from a previous inspection of the service. We spoke with the registered manager, area manager, eleven other staff, five people who used the service and three relatives. We examined the duty rota and other records related to staffing arrangements to make a judgement as to whether the provider was meeting Outcome 13: Staffing and was compliant with Regulation 22 (Health and Social Care Act 2008 Regulated Activities) Regulations 2010.

At this inspection we were satisfied that the service had arrangements to ensure that there were sufficient qualified, skilled and experienced staff in order to safeguard the health, safety and welfare of people who used the service.

People who used the service and their relatives informed us that they were satisfied with the care provided and there were sufficient staff on duty. Staff informed us that the staffing arrangements had improved and on the whole there were enough staff on duty. We observed that people appeared well cared for and those who spent time in the lounges were being supervised by staff.

We spoke with eight people who used the service and three relatives. They indicated that people who used the service had been treated with respect and dignity. One person stated, “the staff are friendly and respectful”. Another said, “they are nice to my relative and understand his needs”.

People who used the service and their relatives informed us that overall, the care needs of people had been attended to and they had access to healthcare services. This was reiterated by two visiting professionals. Assessments, including risk assessments had been carried out. Care plans had been prepared and these were reviewed regularly. There were suitable arrangements for the administration of medication. The home had a varied programme of activities. However, four people who used the service and two relatives stated that there were insufficient staff on duty. They explained that there were insufficient activities and some people who used the service did not get the opportunity to be as mobile and as active as possible.

We spoke with nine staff. We found that staff were knowledgeable regarding the care needs of people. Staff records indicated that they had been provided with essential training. However, with one exception, they informed us that the staffing levels were inadequate and they had difficulty attending to the needs of people. They explained that a large number of people required a high level of care because of the their medical conditions and frailty. We noted that some people were not adequately supervised by staff and we witnessed an incident where people were put at risk of harm.

The home had a complaints procedure. Complaints made had been responded to. A record of compliments and cards from relatives expressing gratitude for the care provided was available in the reception area.

During our inspection of Brook House we were accompanied by an expert by experience for three hours of the visit. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and /or social care service.

We spent most of the time talking to people using the service and to their relatives and/or significant others to gain their views about what it was like living in the home. Due to the complex needs of a significant number of people using the service who were unable to tell us about their experiences of living in the home, we spent time observing people which included looking at their interaction with staff and others. Other people using the service responded to our questions by gestures and signs.

During our visit people using the service showed signs of ‘well being’. People were well dressed; they smiled and laughed, talked with other people using the service and approached staff without hesitation. We observed staff supporting people in a friendly, sensitive and professional manner and we saw that people participated in some activities.

The home was warm, clean and had a relaxed and welcoming. People told us that they liked their bedrooms, enjoyed the food and chose what to eat. They informed us they felt safe and knew who to talk to if they had any worries or concerns.

People confirmed they were listened to, had their needs met, had the opportunity to participate in a number of activities of their choice. They told us they were given the care and support they wanted and needed and they received advice and treatment from health and social care professionals. However one person told us they had on occasions had to wait sometime for assistance from staff, and we found that staff took several minutes to respond to a call bell.

People who use the service told us that staff respected their privacy, and understood their needs. They and their relatives told us that the registered manager was very approachable and they could talk to him and to other staff about any issues in the home, and these were responded to promptly.

People also told us they had access to hospital appointments and to health care and social care professionals such as doctors, opticians, chiropodists and social workers.

We received several very positive comments about the home from four visitors, and from two health care professionals. They told us that there was good communication with the home about people’s needs and changing needs.

Staff told us they enjoyed their job supporting and caring for people at Brook House. They confirmed there was good teamwork and they felt well supported by management staff and received the training that they needed to carry out their role and responsibilities.

There were a number of systems in place to monitor and to make improvements to the quality of care and support provided to people by the home.

Peoples’ comments about the service included, “It’s very good here”, “I am very lucky to have a big room with things of my own”, “I get up and go to bed when I want”, “They (staff) are very friendly”, “The home is homely”, “I am so grateful to them (the staff)”, and “I would recommend it (the home)”.

As part of this review, we spent time on each unit of the home, talking with people using the service to gain their views about living in Brook House. Throughout our visit we saw signs of people’s ‘well being’ (happiness, comfort, welfare, safety and health). People were well dressed, smiled and laughed.

People were generally positive about the care, and support they received at Brook House. They told us; they liked living in the home, they had their health needs met, staff listened to them, and provided them with the care and support they wanted and needed. Comments from people included; “staff help me”, “I have my room as I like it”, “staff give me the help”, “I tell staff what I like”, “staff provide the care that I want”, “I listen to music”, “I watch television, and sometimes go out”, “ I am visited by people from my church”, “I recently celebrated my birthday here”, “It’s fine here staff are really nice”, “I’ve been out many times”, “I can choose what to eat”, and “I have the food that I want”,

People spoke of the staff being “friendly”, “nice”, and “approachable”, but “sometimes I don’t understand staff and they don’t understand me”. Some people were not clear as to whom their key workers were.

People informed us they had the opportunity to participate in a range of activities.

They told us they felt safe living in Brook House, and knew who to talk to if they had any worries or concerns. People confirmed that they felt staff would respond to these in an appropriate manner. Some relatives/visitors told us they sometimes found it took a while for staff to take action in a consistent manner in response to issues they had reported about the care of the person using the service.

People confirmed that they attended healthcare appointments and had contact with a variety of other health care and social care professionals.

People were positive about the environment of the home and were happy with their bedrooms. Some people told us they had personalised their rooms, and brought furniture with them from their home.

Visitors told us they had visited the home before their relative moved in and had liked the atmosphere. They told us they had the opportunity to attend ‘relatives’ meetings, where they could provide feedback about their views of the service. Comments included; “the staff are lovely”, the “staff are wonderful”, “we have confidence in the staff”, “staff call us if they need to”, the manager is “lovely”, the manager is “devoted to his charges and his team”, "the manager is very good”, and “staff are always checking on my (relative)”. A person told us they thought there were not always enough staff particularly in the afternoons.

Staff spoke of enjoying their job, and told us they were busy, there was good team work, and the manager was approachable. Staff confirmed they received the training and support they needed to carry out their role and responsibilities, but there were times, particularly at weekends and during some evenings when they felt there would be benefit to people to have more staff on duty.