About the service: Brookes House is a ‘care home’ that was providing personal and nursing care to 30 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

The service was not always safe. At the last inspection, we imposed restrictions on the registered provider, to not allow them to admit anyone new to the service. They had adhered to this instruction. Following the last inspection, a number of safeguarding incidents had occurred and some were being investigated by the local authority. The registered provider did not always deliver a safe service to people, that was supported by consistent, competent and responsive staff. After the last inspection, people had experienced a change in staffing, because occupancy had decreased and staffing levels had stayed the same. Staff competency when delivering care had improved. At the last inspection, people's medicines had not been administered correctly. At this inspection, people were receiving their medicine in the right way.

The service was not always effective. For a prolonged period of time, the registered provider found it difficult to ensure that people consistently achieved good outcomes and received good care. At this inspection, people did not always receive good oral health care. The service did not always involve people in the design and decoration of the service. Assessments were in place but these could be developed further to consider a wider range of needs of the whole community, such as LGBTQ. People’s meal experiences had improved.

The service was caring. Whilst people had not always experienced a caring service, people told us they were being treated with dignity and respect. Staff treated people in a kind and caring way and had been involved in reviews of their care.

The service was not always responsive. Complaints were not dealt with by people who had the right level of knowledge and skill, to resolve them in an appropriate way. We have made a recommendation about the way the registered provider handles complaints. At the last inspection, established routines of care were in place. Previously, Staff did not always allow people to have control over their day to day lives and make choices as they would like. For example, people did not always have the choice over when they had a bath, when they got up or went to bed, or where they sat. This had improved. Care plans had been reviewed and were more reflective of people’s needs, they included people's choices about end of life care.

The service was not always well led. The management of the service continued to be inconsistent, and this will be the third time this service has been rated requires improvement. Quality assurance frameworks had not always been used in an effective way, and people had not always been given person-centred or good quality care. However, these systems were being used more effectively and this was beginning to have an impact on the service. People were experiencing a service that had improved from being inadequate.

More information is in the detailed report below.

Rating at last inspection: Inadequate (28/9/18) This is the third time the service has been rated requires improvement.

Why we inspected:

At the last inspection, multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found, and the service was placed in special measures. Services that are in special measures are kept under review and inspected again within six months. This was a planned inspection based on the previous rating. The service had been placed in special measures because there was not enough competent staff to ensure people were safe. Staff had been using manual handling techniques incorrectly and people did not receive personal care in a responsive, dignified and respectful way. Care delivered to people was routine and did not support people to have control over their day to day lives. People did not always receive t

We carried out a comprehensive inspection of this service on the 27 June 2018. Breaches of the legal requirements were found. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements.

This service was placed in special measures because, at our last inspection on the 25 September and the 17 and 19 October 2017, we found the service to be inadequate in the safe domain with a number of breaches of the legal requirements under the Health and Social Care Act, 2008; 2015. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection this service had failed to demonstrate that improvements had been made and continued to be in breach of the legal requirements.

The overall rating for this service is ‘Inadequate’ and the service remains 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 be providing inadequate care should have made significant improvements within the timeframe given. If not, enough improvement is made, so that there is still a rating of inadequate for any key question or overall, we will act 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.

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.”

After the last inspection on the 25 September and the 17 and 19 October 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions and take action to make improvements. This was because there was often not enough staff on duty to provide people with safe care. Staff did not always support people to move in a safe way and some people told us they were not always treated with dignity and respect. This action had not been completed.

Brookes 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. Brookes House accommodates up to 70 people in one adapted building. At the time of the inspection there was 43 people living at the service.

A registered manager had recently left the service, and the service was being managed by a peripatetic manager and an operations 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.

People told us there were not enough staff available to meet their needs. We saw that the deployment of staff in the communal lounge areas were ineffective and they did not always have time to spend with the people they supported.

We observed a number of unsafe manual handling practices. Some people were not satisfied with the personal care they received, and some people had to wait a long time to be helped to the toilet.

The provider had given staff regular training, but even though they had been given training, some sta

We carried out an unannounced comprehensive inspection of this service on the 25 September 2017 and the 17 and 19 October 2017. Breaches of the legal requirements were found. This was because there was often not enough staff working at night. Staff did not always support people to move in a safe way and some people told us they were not always treated with dignity and respect.

Brookes House provides accommodation and personal care for up to 70 older people. Some people also have dementia related needs.

A registered manager was 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.

We received mixed feedback about staffing levels. Some people told us there were enough staff available, but a number of people and staff told us that there wasn’t always enough staff, particularly at night. We saw that the deployment of staff in communal lounge areas was not always appropriate and staff did not always have time to spend with the people they supported.

Before this inspection, we received information of concern and were told that poor manual handling techniques being used. We observed how staff helped people to mobilise who were unable to do this for themselves. We observed a number of unsafe manual handling practices.

The registered manager made sure that staff had regular training, but even though staff had been given training the registered manager did not always make sure that staff were competent to carry out their role safely.

Overall people and their relatives reported high levels of satisfaction. Although this was the case during our inspection, some people were not satisfied and we received several concerns prior to our inspection that people didn’t always receiving a caring service. Front line staff were working well to ensure people’s day to day care was good, however, the management team had failed to provide a safe, effective, caring, responsive and well led approach to people’s care.

Audits and checks were in place and completed regularly. However, these checks had failed to pro-actively address the concerns we had found, specifically in the area of staffing numbers and the competency of staff in relation to manual handling. There was a lack of oversight based on the observations of the care being provided.

People received their medicines correctly and in line with the services policy and procedures. The dining experience for people was positive and people were complimentary about the quality of meals provided to them. Eating and drinking was an important part of people’s daily life and the staff ensured this was a social occasion.

People were supported to have choice and control, and staff supported them in the least restrictive way possible.

Full information about CQC regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We carried out an unannounced comprehensive inspection of this service on 1 and 2 November 2016. Comments about staffing levels from people using the service, relatives and those acting on people’s behalf and staff were found to be variable. Some people and their relatives felt on occasions that there was insufficient staff available to meet their needs or their loved ones needs. Some staff also felt that staffing levels were appropriate whilst others advised that staffing levels were not always maintained and this sometimes impacted on their ability to provide appropriate care for people using the service. Our observations at the time of the inspection showed that the deployment of staff was not always suitable to meet people’s needs and communal lounge areas were frequently left without staff support.

As a result of our concerns a breach of regulatory requirement relating to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was made. We undertook a focused inspection on 18 May 2017 to review the above and to ensure that compliance with regulatory requirements had now been achieved. This report only covers our findings in relation to this area. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Brookes House on our website at www.cqc.org.uk

A registered manager was 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.

Suitable arrangements were in place to determine the basis for the service’s staffing levels so as to ensure these remained suitable and flexible to meet people’s individual care and support needs. Observations showed that the deployment of staff was now suitable to meet people’s care and support needs and communal lounge areas were staffed accordingly to ensure people’s safety and wellbeing. People, relatives and those acting on their behalf were positive about staffing levels at the service. Staff confirmed that staffing levels were maintained.

Brookes House provides accommodation and personal care for up to 70 older people. Some people also have dementia related needs.

The inspection was completed on 1 and 2 November 2016 and was unannounced. There were 57 people living at the service when we inspected.

A registered manager was 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.

People and those acting on their behalf did not always think that there were sufficient numbers of staff available to meet their needs. The deployment of staff in communal lounge areas was not always appropriate and staff told us that they did not always have time to spend with the people they supported.

Minor improvements were needed to ensure that medicines management were conducted in line with the provider’s policies and procedures. People told us the service was a safe place to live. Staff had a good understanding of safeguarding procedures to enable them to keep people safe.

Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs, so as to ensure theirs’ and others’ safety. Staff understood the risks and signs of potential abuse and the relevant safeguarding processes to follow. Risks to people’s health and wellbeing were appropriately assessed, managed and reviewed. Staff were friendly, kind and caring towards the people they supported and care provided met people’s individual care and support needs.

Staff received opportunities for training and this ensured that staff employed at the service had the right skills to meet people’s needs. Staff felt supported and received appropriate formal supervision. Staff demonstrated a good understanding and awareness of how to treat people with respect and dignity.

The dining experience for people was positive and people were complimentary about the quality of meals provided. Consideration by staff was evident to ensure that eating and drinking was an important part of people’s daily life and treated as a social occasion.

Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been made in their best interests. The manager was up-to-date with recent changes to the law regarding the Deprivation of Liberty Safeguards (DoLS) and at the time of the inspection they were working with the local authority to make sure people’s legal rights were being protected. People who used the service and their relatives were involved in making decisions about their care and support.

There was an effective system in place to regularly assess and monitor the quality of the service provided. The manager was able to demonstrate how they measured and analysed the care provided to people, and how this ensured that the service was operating safely and was continually improving to meet people’s needs.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection was conducted by two inspectors. During our inspection we spoke with a total of 14 of the 53 people who used the service and 10 relatives. We also spoke with a senior representative of the organisation, the manager, deputy manager, six members of staff and one healthcare professional. The manager had been in post at Brookes House since 2 July 2014. An application to cancel the previous manager's registration with the Care Quality Commission was received on 15 September 2014.

We looked at nine people’s care records. We also looked at the provider’s arrangements for obtaining and acting in accordance with the consent to care and treatment for people who used the service. In addition, we looked at the provider’s arrangements for meeting peoples nutritional needs, the management of medicines, staffing the service to meet peoples care and support needs, records relating to staff training and supervision and; the provider's arrangements to monitor the quality of the service provided.

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?

We looked at staffing levels at the service. On the day of our inspection we found that there were sufficient staff available to meet people’s care and support needs.

CQC monitors the operation of the Deprivation of Liberty Safeguards [DoLS] which apply to care homes. At the time of our inspection two DoLS applications had been submitted to the Local Authority where people were considered to being deprived of their liberty. An assessment for those people who lacked the capacity and ability to make some specific day-to-day decisions about their care and support had been completed. However, we found that information was not recorded and people had not been consulted about the use of a sensor mat or where their medication was covertly administered. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the Mental Capacity Act [MCA] 2005 and DoLS.

We found that improvements had been made to ensure that people who used the service were protected against the risks associated with the unsafe use and management of medicines.

We observed on two separate occasions unsafe and poor manual handling procedures by staff when assisting people in their wheelchair.

Is the service effective?

We found that not all of the information recorded within people's care records accurately reflected their needs and the care and support to be provided.

The provider was not able to demonstrate that they had an effective system in place to support staff so that they could carry out their roles and responsibilities. This referred specifically to newly employed staff not receiving a comprehensive induction or regular supervision. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting workers.

We found that the dining experience for people at Brookes House was variable. The dining experience for people on the ground floor was seen to be positive. This was in contrast to the dining experience for people on the first floor. We found that the support provided by staff for people who required assistance to eat and drink was not timely and people were not enabled to eat their food and drink as independently as possible. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to meeting people's nutritional needs.

Is the service caring?

People told us that they were happy with the care and support they received. We found that staff relationships with people who used the service were seen to be caring, kind and considerate. Staff we spoke with were able to demonstrate a good understanding and knowledge of people's individual care needs.

People who used the service had a care plan in place detailing their specific care needs and the support to be provided by staff.

Is the service responsive?

An effective system was in place to deal with comments and complaints received from people who used the service, those acting on their behalf and other third parties.

Our observations showed that people who used the service were supported to participate in a range of meaningful daytime activities.

People who used the service were supported to maintain important relationships that mattered to them.

We were not assured that people had their personal hygiene needs met in line with their specific care needs.

Is the service well-led?

The provider was not able to demonstrate that there were suitable arrangements in place to assess and monitor the quality of the service provided. Our findings showed that lessons had not been learned from previous inspections and a proactive approach had not been taken to drive and maintain improvement.

During our inspection of 12 February 2014, we spoke with seven people who used the service. We also spoke with eight members of care staff, the registered manager, deputy manager and two provider's representatives. We spoke with four visitors to people who used the service and a visiting professional. We looked at care plans for eight people.

The provider was in the process of updating their registration with the Care Quality Commission to reduce their maximum occupancy capacity to 56 people. On the day of our inspection, the home was not at full capacity and there were 47 people living at the service.

The provider did not have suitable arrangements in place to obtain and act in accordance with the consent of people who used the service. We found continued non-compliance with this regulation.

When we visited the service on 14 August 2013, we found that there was an insufficient number of staff on duty. At our inspection of 12 February 2014, we found that this was no longer the case. People and visitors to the service confirmed that there were enough staff. One visitor to a person who used the service told us, “There’s staff galore in here! Everywhere you turn there’s staff. Any time you ask them for anything they come straight away.”

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

As part of this inspection we spoke with ten people who used the service, a visiting relative, six members of staff, the manager and the area manager. We looked at five peoples' care records. We also looked at files relating to three staff which included training, recruitment, supervision and appraisal records.

We directly observed care within the service to help us determine what it was like for people who lived at Brookes House. We found that staff interactions with people who used the service were positive and that staff had a good understanding of people's individual care and support needs.

People who used the service told us they liked living at Brookes House and found the majority of staff to be kind and caring. One person told us, “The staff have met all my support requirements up to now. It amazed me; they all knew my name as soon as I got here.” A relative told us that they were very happy with the care and support provided for their member of family.

The inspection showed that improvements were required in relation to consent to care and treatment, care planning, staffing levels and the provider’s systems to monitor the safety and quality of the service provided to people living at the home.

We spoke with seven people who used the service, two visiting relatives and a healthcare professional during our inspection visit on 31 August 2012. People who used the service told us they were satisfied with the care they received. Comments included, “The care is good and I love the activities, all in all I am very happy here”, and “The staff do look after me well”.

Information received from visitors was conflicting. One person was very unhappy with the care provider by the home to their relative, describing it as “poor”. The other visitor spoke very highly of the care and service provided to their relative who said, “The care is very good, physically and emotionally.”

The healthcare professional told us that they were in the home regularly and felt that staff monitored people’s care effectively and called for professional support promptly. They said, “The care of residents seems fine from what I see.”

People told us they enjoyed the food and social activities available and were able to exercise choice in their daily lives. People told us that staff were kind and they felt safe living at the home. They also told us that staff worked hard and were very busy. This meant that people often had to wait before staff were able to give them care and support.

Some people were unable to provide a verbal response or tell us verbally about their experiences as a result of their limited verbal communication or poor cognitive ability. We spent time observing and noted their non-verbal clues. These indicated that people were relaxed and comfortable and found their experience at the home to be positive.

Brookes House provides accommodation, personal care and nursing care for up to 70 older people. Some people have dementia related needs.

The inspection was completed on 17 December 2014 and 18 December 2014 and there were 49 people living at the service when we inspected.

A registered manager was 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.

The last inspection on 4 September 2014 found that the provider was not meeting the requirements of the law in relation to consent to care and treatment, meeting nutritional needs and supporting workers. We also found that the service had failed to ensure that people’s care needs were met and and an effective system to monitor the quality of the service implemented. An action plan was provided to us by the provider on 4 December 2014. This told us of the steps taken and the dates the provider said they would meet the relevant legal requirements. During this inspection we looked to see if these improvements had been made.

Staffing levels and the deployment of staff to meet the needs of people who used the service were not appropriate to meet people’s needs.

Suitable arrangements were not in place to respond appropriately where an allegation of abuse had been made.

Cleanliness and infection control procedures at the service required improvement.

The service did not have an effective system in place to deal with people’s comments and complaints.

We found that an effective system was in place to regularly assess and monitor the quality of the service provided. The registered manager was able to demonstrate how they measured and analysed the care provided to people who used the service and how this ensured that the service was operating safely. However, the provider’s quality assurance system had not picked up the identified areas of concern that we found.

People and their relatives told us the service was a safe place to live. Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs, so as to ensure their and other’s safety.

We found that risks to people’s health and wellbeing were assessed.

We found that the management of medicines was suitable and the majority of people received their medication safely.

Staff told us that they felt supported and valued. Staff told us that they received regular training opportunities. We found that staff received a robust induction, supervision and appraisal.

Comments about the quality of the meals provided were complimentary and the dining experience for people was positive.

People told us that their healthcare needs were well managed and we found that the service engaged proactively with health and social care professionals.

Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been made in their best interests.

We found that people’s care plans were reflective of their care and support needs. Improvements relating to the accuracy of some records were required.