About the service: Brownhills Nursing Home is service that provides accommodation, nursing and personal care for up to 50 people. At the time of our inspection, 45 older people were living in the home, some of whom may have a physical disability and/or dementia.

Brownhills Nursing Home 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 home is in one adapted building over two floors.

Rating at last inspection: At the last inspection the service was rated Requires Improvement. The report was published 18 March 2018.

Why we inspected: This was a scheduled inspection based on the previous rating.

People’s experience of using this service:

¿ People continued to tell us they felt safe and well supported.

¿ Staff had a good understanding in how they protected people from harm, and recognised different types of abuse and how to report it.

¿ Incident reports were not reviewed in a timely way and action taken to address this was inconsistent.

Potential risks to people had been identified and people had involved with decisions in how to reduce the risk of harm.

¿ There were enough staff on duty to keep people safe and meet their needs.

¿ People’s medicines were managed in a safe way. However people's prescribed creams were not stored securely.

¿ Safe practice required improvement to reduce the risk of infection.

¿ People’s care continued to be assessed and reviewed with the person involved throughout.

¿ People were supported to have a healthy balanced diet and were given food they enjoyed.

¿ 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 support this practice.

¿ Staff worked with external healthcare professionals and followed their guidance and advice about how to support people following best practice.

¿ Staff treated people as individuals and respected the choices they made.

¿ People’s care was delivered in a timely way, with any changes in care being communicated clearly to the staff team.

¿ People were not always supported to maintain their hobbies and interests. The upstairs communal area did not always meet people's social needs.

¿ People had access to information about how to raise a complaint, where complaints had been received the provider had managed these in line with their policy.

¿ The registered manager was visible within the service, they spent their time listening to people, relatives and staff.

¿ The registered manager had failed to consistently notify CQC of all notifiable incidents that happened within the service.

¿ The registered manager did not always clearly evidence action they had taken to address shortfalls reported within the service.

¿ The checks the registered manager made to ensure the service was meeting people’s needs focused upon people’s views and experiences.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

Enforcement: Action we told provider to take (refer to end of full report)

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Our inspection took place on 22 and 27 November 2017 and was unannounced. We last inspected the service on 15 February 2017 and found the service requirement improvement across four of the key areas we inspect, with a rating of ‘good’ in the question, ‘Is the service responsive?’ This is the fifth consecutive time the service has been rated Requires Improvement.

Brownhills Nursing Home 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.

Brownhills Nursing Home accommodates 50 people in one adapted building. At the time of the inspection there were 48 people living at the service.

There was 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.

Staffing levels, staff sickness and the deployment of staff across the home could not ensure that people’s needs were met in a timely manner. The combination of new and agency staff meant not all staff were fully aware of the risks to people on a daily basis. New staff were provided with an induction to prepare them for their role but systems were not in place to ensure agency staff received the same level of information in order to meet people’s needs.

Staff were aware of their responsibilities to keep people safe and had received training in how to recognise abuse and respond to any concerns raised.

People told us they felt safe. People were supported with their medication and were noted arrangements in place for the management of medication was safe. There were systems in place to reduce to risk of infection but these were not always followed by staff.

Where accidents and incidents took place, lessons were learnt and actions taken to reduce future risks.

Pre-assessments of people’s care needs took place prior to people moving into the home. Staff were provided with training in order to meet the needs of the people they supported safely and effectively.

People were supported to have enough to eat and drink to help maintain a healthy diet. A variety of healthcare services were available to people in order to meet their needs. Staff were aware of people’s healthcare needs and referrals were made to a variety of healthcare services in order to meet people’s needs.

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.

People were not always treated with dignity and respect. The approach to care was task led and people could not be confident that they would consistently be treated with kindness and compassion. People were supported to make choices regarding their daily lives and were supported to access advocacy services.

Staffing issues and the poor deployment of staff across the home continued to have an impact on care delivery. Staff recognised the positive changes introduced by the registered manager but were concerned that staffing levels across the home required improvement. The provider and registered manager were actively looking for solutions to improve staff recruitment and retention.

The registered manager worked in partnership with other agencies in order to improve care delivery. Systems were in place to obtain feedback from people living at the service.

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

Our inspection took place on 15 February 2017 and was unannounced. We last inspected the service on 6 and 7 July 2015. We found the service required improvement across all five of the areas of care we inspect. We also found that the registered persons were not meeting regulations in the areas of safety in respect of staffing levels and leadership in respect of feedback on the service. We received an action plan from the provider telling us how they were going to address these issues. At this inspection we found that some improvements had been made.

Brownhills Nursing Home provides accommodation for up to 50 people requiring personal care who may have dementia and who may have physical disabilities. At the time of the inspection there were 46 people living at the service.

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.

People did not always receive support from sufficient numbers of staff. While some improvements in staffing had occurred since our last visit, people did not always receive the support they needed in a timely way.

Staff demonstrated skill in supporting people safely while assisting them to move about the service. However, some improvement in risk assessments were required to ensure staff had updated and accurate information about people’s requirements.

Staff received training which meant they were knowledgeable about how to support people appropriately. Staff were not always clear about how to support people who may lack capacity to make certain decisions. Some people’s records did not contain best interests information to assist staff where people may lack capacity in this way. Staff checked people were consenting to their care before they supported them.

People felt they received safe care from a staff group who were appropriately and safely recruited. People’s health was supported by correct medicines in order to support their health.

During our last inspection we found people did not always receive a choice of food or drink. During this visit we found people were offered choice and were happy with the amounts of food and drink they received.

People were supported to receive appointments with healthcare professionals in order to support their wellbeing. People received compassionate care from staff, which protected their dignity. We found improvements in care record security was needed.

Most people were able to participate in stimulating activities, although this was less apparent on the first floor of the service. The registered manager was making improvements to care records to ensure they were more person centred.

The provider sought feedback from people and their relatives in order to identify areas for improvement at the service. People had access to information about to how to raise a concern.

During the last inspection we found the service lacked leadership in respect of driving improvement. The provider now had new systems, but this had not addressed all issues, such as staffing levels. We found in other areas the provider had improved their oversight of the service. People and staff were positive about the culture and management of the home.

This inspection was unannounced and took place on 6 and 7 July 2016. At the last inspection in July 2015, we found the provider was meeting the regulations however improvements were required in relation to staffing levels and activities. At this inspection we found improvements were still required.

Brownhills Nursing Home is registered to provide accommodation with nursing and personal care for up to 50 older people including people with dementia and people with physical disabilities. On the day of the inspection there were 47 people living at the home. The home had been without a registered manager since May 2016; however there was a new manager in post who had submitted an application to become registered. 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 did not always received support from sufficient numbers of staff, which meant their needs were not always met in a timely way. People told us they felt safe and we found they were supported by staff who knew how to protect people from harm. Risks to people’s safety had been assessed and care and support was delivered in a way that kept people safe from harm. People received their medicines as prescribed and systems used to manage medicines were safe.

People were not offered choices in terms of food and drink. People were supported by staff who felt they had received training to equip them to do their job. People were asked for their consent before care and support was provided by staff. People’s capacity had been assessed and recorded so that staff knew how to support people when making choices and decisions. People had access to healthcare when they required it and people’s health needs were monitored by staff and any changes were identified and reported.

Staff were not always aware of people’s needs and preferences. People told us staff were caring but did not always have time to spend with them. People told us they were not always involved in decisions about their care. People were supported by staff in a way that maintained their dignity and protected their privacy.

People and their relatives told us there were not enough leisure opportunities and people were not always encouraged to follow their interests or hobbies. People knew how to complain if they were unhappy about the care they received and there were processes and systems in place to manage complaints.

People, relatives and staff did not always feel the home was well managed. Systems in place to monitor the care provided were not effective in making the improvements required that were identified at the last inspection. Staff expressed their confidence in the manager who they felt had made positive changes to the home. The manager demonstrated the skills and knowledge required for their role.

During this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We inspected Brownhills Nursing Home on 29 July 2015. The inspection was unannounced. At the last inspection on 8 January 2015, we had identified a breach of regulations. We found the provider had not followed guidance provided by the local authority safeguarding team with regard to the installation of close circuit television (CCTV) cameras. We also found some people’s dignity had not been respected. We asked the provider to make improvements in these areas and this action has been completed. They sent us an action plan stating they would meet the legal requirements by 11 May 2015. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. We also followed up on concerns we had received before the inspection. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Brownhills Nursing Home on our website at www.cqc.org.uk

Brownhills Nursing Home provides accommodation, nursing and personal care for up to 50 older people with a range of needs. There were 40 people living at the home when we visited. The home did not have a registered manager in post. The provider had appointed an acting manager who had submitted an application to CQC to become registered 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 newly appointed acting manager was not present at the inspection and we were therefore assisted by the area manager.

People were not always supported by sufficient staff numbers. There was a recruitment procedure in place which was followed. This ensured staff were appropriately checked before they started work at the service.

Staff did not always show a commitment in respecting people’s dignity Staff had a good understanding of people’s needs. The CCTV had not been switched on since the last inspection and it was confirmed that this would remain the case for the foreseeable future.

A varied menu was in place and people told us they enjoyed the food. The provider did not support people to follow their individual interests. There was a lack of stimulating social activities available for people to access.

This inspection took place on 8 January 2015. The inspection was unannounced. At our last inspection in June 2014, the home was not meeting five of the regulations inspected. After that inspection we wrote to the provider and told them to take action to improve care planning and delivery of people’s care, quality assurance audits, the environment, people's privacy and dignity and gaining consent from people. The provider sent us an action plan to tell us the improvements they were going to make. At this inspection improvements had been made in some of the required areas. However, we found the provider had not been proportionate with gaining consent from people with regard to the installation of close circuit television cameras. Nor had the provider considered the potential impact of the people who lacked capacity. We found this to be a breach in regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Brownhills Nursing Home provides accommodation, nursing and personal care for up to 50 older people with a range of needs. There were 35 people living in the home when we visited. There was no 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.

People told us they felt safe living at the home. Systems were in place to reduce the risk of harm and potential abuse. Staff were trained on how to protect people from harm. All of the staff knew how to report any concerns they had if they saw bad practice.

Risks were identified and plans were in place for staff to follow to minimise such risks. Medicines were managed in accordance with guidance which ensured people’s safety. The clinical commissioning group visit identified minor improvements were required with medicines management, this related to recording issues. The manager had begun to improve this area.

Staff had been recruited following appropriate recruitment and selection policies and procedures. This meant people had been properly vetted before they were offered employment at the home. We saw that there were sufficient numbers of staff on duty to meet the needs of the people who lived at the home.

Staff understood the needs of people that lived at the home. We saw staff treated people with kindness and compassion and were aware of each person’s needs.

People’s ability to make their own decisions and consent to their care had been appropriately sought which meant people’s rights were protected.

The new manager had addressed some long standing staffing issues with regard to inherent culture within the staff group. Staff were clear of the expectations required of them.

The assessment and the planning of people’s care was thorough and ensured staff had good information about people's individual needs and preferences. Positive engagement took place between staff and people who lived at the home. People had a variety of activities available to them.

A complaint policy was in place. Complaints were well-managed and people concerned were listening to and acted upon.

People and staff were positive about the manager. Not all staff had received support from the previous registered manager to carry out their work. However, the new manager had begun one-to-one meetings with staff to ensure they were properly supported to provide care and support to people who lived at the home.

People had access to healthcare professionals for example, their doctor who they could discuss their health needs with. People's nutrition and hydration was assessed and where somebody was at risk of malnutrition appropriate support and advice had been sought.

Brownhills Nursing Home provides accommodation and nursing care to elderly people who may also have a dementia related condition.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

We saw that action had been taken to address the concerns we raised at our last inspection for medication practices. Medicines were now managed safely and we saw that people were supported to take their medicines as prescribed. Medicines were administered by nursing staff who had been trained to administer them appropriately. The nursing staff knew how to check that people were receiving their medicines safely and as prescribed.

The home environment was not always maintained to a safe standard. Risk assessments had not been considered for open staircases and the risk of falls. We identified that people could access the roof area through an unlocked door. Parts of the home and equipment were not cleaned thoroughly and systems in place did not identify where improvements in these areas could be made.

The registered manager and staff did not understand how decisions should be made in people’s best interests through The Mental Capacity Act 2005.This sets out how to act when people do not have capacity and informs the staff what guidelines must be followed. The provider had not ensured that only people who had legal authority to do so, made appropriate decisions and these were only made in people’s best interests where they no longer had capacity.

There were no people having restrictions placed on them through the Deprivation of Liberty Safeguards (DoLS). These safeguards apply where it is thought that it is in someone's best interests to be placed in a care home but they lack the capacity to make a decision about what is being proposed for them. In these circumstances the provider must apply for authorisation to deprive the person of their liberty.

On the day of our inspection the service was visited by health and social care professionals in response to concerns raised by a visiting professional. As a result of their visit, people using the service were to receive a review of their individual care to ensure the provider could meet their needs safely and effectively.

Is the service effective?

The care records included information about risks and actions to take to reduce these. We saw staff supporting two people to move around the home effectively and this matched what we saw had been recorded in the care records. Other information we looked at did not always include accurate information about how people were to be supported and whether they were able to make decisions for themselves. This meant that some care did not reflect how people may want to be supported.

People using the service were able to access doctors, nurses and dieticians when required. We saw the advice of healthcare professionals was incorporated into people’s support plans but staff were sometimes unaware of or did not follow this advice.

People were supported to change position in bed to prevent pressure damage without using the required specialist moving and handling equipment. This meant some people were placed at further risk of skin damage.

Is the service caring?

The staff knew the interests of people and their life history and we saw staff holding a meaningful conversation with people. People using the service told us the staff would talk with them and they felt that the staff treated them kindly. We observed staff supporting people respectfully and ensuring their privacy was maintained when supporting them to move and providing personal care.

We saw that people were not always supported to maintain their dignity with how they looked. The staff identified that some people’s clothes needed changing as they were unclean. However, they did not provide the support needed to change clothes when people confirmed they wished to.

Is the service responsive?

Activities were organised in the home by staff, but these were not always implemented as planned. There were limited activities to support people with dementia related conditions. There was an activity board which displayed what was planned in pictorial form to support understanding, but these had not been changed to reflect the right calendar month and the two clocks in one lounge showed different times which could confuse people. This meant information that was designed to help people know what was happening and the time and date was not helpful to people.

People’s views about the care they received were sought through questionnaires and relatives and visitors were asked to comment about the service. We saw that completed questionnaires showed that people using the service and relatives were positive about the care they received and these results were available for people to view in the reception area.

Is the service well-led?

Systems were in place to assess and monitor the quality of the care provided. Some of the systems in place were not always effective, as the concerns we identified during our inspection had not been recognised by the provider.

The service had a registered manager who was responsive to the concerns we identified and agreed improvements were required to ensure people received safe effective care.

The visit to Brownhills Nursing Home was unannounced. This meant the provider, manager and the staff did not know we were coming. We visited the service to ensure people were receiving appropriate care that met their needs.

During the inspection with spoke with nine people who lived at the home, three visitors, six staff members, the registered manager and the area manager. Generally the feedback from people was positive.

The local authority had visited the home to review the care and welfare of people living there. To ensure people received sufficient fluids to keep them hydrated advice and guidance had been provided to the home by the local authority. On the day of the inspection we saw that this advice was being followed.

We looked at how medication was managed within the home. Systems were in place to store and dispense medicines prescribed by a doctor. When auditing the quantity of tablets in the home we identified some errors in recording.

Recruitment procedures were in place, this included appropriate checks to ensure people were suitable for employment at the home. We saw that training records were available and staff told us they felt appropriately trained and supported in their role.

The provider and manager had systems in place to monitor the quality of the service provided at Brownhills Nursing Home.

We visited Brownhills Nursing Home to up date the information we hold about the service and to establish whether the service had made any improvements since we last visited. The provider had sent an action plan detailing what they had done to meet the regulations. We used this information to check to the improvements that were required. The visit was unannounced which meant the provider and the staff did not know we were coming.

We had identified non compliance in relation to the care and welfare of people who used the service. On this occasion we saw that improvements had been made in this area. We found care plans gave staff the necessary information required to deliver care to people living at the home. Records were completed to support the care delivery described by staff. People living at the home we spoke with reported that they were happy and felt safe. We saw people appeared relaxed and the atmosphere was calm.

During our last inspection we had been concerned about the number of staff on duty. During this inspection we found the staffing levels had increased. One staff member said, “We are a stable staff group but with the recent employment of more English speaking staff it is much better”. A visitor to the service said, “I have noticed a real difference since you were here last, let’s hope they keep it up”.

We looked at the process in place to monitor the quality of the service provided at the home. We found quality monitoring process were in place

We carried out this inspection to check on the care and welfare of people using this service. We visited Brownhills Nursing Home in order to up date the information we hold about the service and to establish whether the service had made any improvements since we last inspected the service on 18 July 2012. This inspection was unannounced which meant the provider and the staff did not know we were coming.

The service provided 50 nursing and residential places to adults. There were 41 people living at the home at the time of our inspection.

Care plans gave details of the care requirements for people living at the home; however recordings did not always confirm care delivery had been given. We observed, and we were told, by a visitor of poor moving and handling techniques used by staff. This had also been identified at a previous inspection.

During our last inspection we had been concerned about the number of staff on duty at the home. During this inspection we observed people who used the service sitting for periods of time with little support or stimulation.

During the inspection we looked at the process the service had in place to monitor the quality of the service provided at the home. We asked the provider for additional evidence following our inspection. At the time of submitting the draft report we had not received the information we asked for.

Our previous review in March 2011 had identified that improvements had to be made to ensure people receive the care they need. We spoke to six people who use the service, seven relatives, and three staff.

We saw that staff did not always meet people’s request for personal care in a timely manner. One person told us, “This morning I waited half an hour to be taken to the toilet, I am not happy about that.”

One relative told us, "I am quite happy with the care." We saw that relatives visiting the home could spend time with people in the lounge or in people's bedroom, where their privacy was respected.

The previous review highlighted that people did not have confidence in management to address their complaints. At this review, a relative told us they are “not completely happy with the service,” but that they have “given up complaining as nothing happens.”

We found that required actions for improvement had not taken place and many issues had not been resolved since our previous review.

We carried out this review to check on the care and welfare of people using this service. We visited Brownhills Nursing Home in order to up date the information we hold about the service and to establish whether the service had made any improvements since we last visited. The visit was unannounced which meant the provider and the staff did not know we were coming.

We involve people who use services and family carers to help us improve the way we inspect and write our inspection reports. Because of their unique knowledge and experience of using social care services, we have called them experts by experience. Our experts by experience are people of all ages, from diverse cultural backgrounds who have used a range of social care services.

The service provided 50 nursing and residential places. There were 40 people living at the home during our inspection. The local authority had raised concerns about the quality and the safety of the service. These concerns had been investigated and monitored by the local authority along with other relevant professionals. During this time the local authority had stopped new placements of people into the home. At the time of our visit the suspension was still in place, however this was under review. Following our visit we were informed by the local authority, that following a review of the service they had removed the suspension of placements and would continue to support and monitor the service.

During our visit we used a number of different methods to help us understand the experiences of people using the service. This is because some people had complex needs which meant they were not able to tell us their experiences. We used our SOFI (Short Observational Framework for Inspection) tool to help us see what people's experiences were like within the home. The SOFI tool allowed us to spend time watching what was going on in the service and helped us to record how people spent their time and whether they had positive experiences. This included looking at the support that was given to them by the staff. We observed interactions between staff and people using the service, spoke with 14 people who lived at the home, three people visiting friends and relatives, seven staff members and the manager.

An expert by experience took part in this inspection and talked to staff and people who were living in the home. They looked at what happened around the home and saw how everyone was getting on together and what the home felt like. They took some notes and wrote a report about what they found, the details are included in this report.

A relative who was visiting the service told us, “I am happy with care here, my relative has had a new lease of life. They said “In general care staff are very good, I go home confident and am kept informed”. Another person said, “The manager is great, there have been a few teething problems and I have made some complaints to the manager, they always sort it out. People living at the home were complimentary of the staff and staff told us they enjoyed working at the home,

Through a process called 'pathway tracking' we looked at care plans, spoke with people about the care they received and asked staff about how they provided support. This helped us establish whether people were getting appropriate care that met their needs and supported their rights. The staff we spoke with were knowledgeable about the care requirements of the people living at the home. Care plans were easy to follow and the information held in them assisted staff in care delivery. However, in the four care plans we viewed there were occasions when documentation in the plan had not been updated which led to some gaps in recordings.

During our last inspection we had been concerned about the number of staff on duty at the home. During this inspection we observed staff were available to deliver personal care to people but not to support people with activities. The service did not have a system in place to assure itself of sufficient staffing.

We looked at staff training during the inspection. We saw from training records that all staff had completed training for moving and handling. During the inspection we saw instances when instruction from training was not being followed.

During the inspection we looked at the process the service had in place to monitor the quality of the service provided at the home. We found that there were some systems in place to audit the service and seek feedback from the people who used the service.