We inspected Brunswick House on 11 and 12 February 2019. The inspection was unannounced.

Brunswick House is a 'care home' and provides accommodation and personal care for up to 46 older people, including those living with dementia. 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. At the time of our visit 40 people were using the service.

We last inspected the home on 20 and 22 February 2018 and found five breaches of the legal requirements. People did not always receive safe care and good medicine practices were not always followed. When people had been deprived of their liberty for the purpose of receiving care or treatment lawful authority had not been sought. Staff were not appropriately trained and supported and people did not always receive personalised care. The provider’s quality monitoring systems had not been effective in identifying these concerns prior to our inspection and action had not been taken promptly to improve the service people received.

During this inspection we found that improvements had been made and the provider met legal requirements. We found people’s plans of care had improved and contained detailed information about their individual needs and preferences. Medicine practices had improved. There were systems for ensuring people were not being deprived of their liberty without lawful authority and a new co-ordinator for training had been employed. Staff induction training and mandatory training had been completed as required by the provider's policy. Plans were in place to ensure staff one on one supervision and refresher training were provided in line with the provider's policy.

The service had a registered manager who registered with CQC in January 2019. 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 registered manager had implemented the service action plan to address the shortfalls in the service and had implemented improvements as required. There was a clear vision for the delivery of good quality care to people and a positive culture within the staff team.

People and their families did not always know what was contained in care records, and people did not have the opportunity to review information held about them.

There was an activities coordinator in place however, more time was needed to imbed a full activities program to support people to maintain or improve their health and mental wellbeing within the home.

Information for people within the home was not always presented to them in a way they could understand.

People told us they felt safe living at the home and we saw there were effective safeguarding processes in place to protect people from the risk of harm. Staff were knowledgeable about the procedures relating to safeguarding and whistleblowing.

Safe recruitment checks were carried out and there were adequate numbers of staff to meet people's needs safely.

Risks to people had been assessed and managed appropriately. Staff followed safe moving and handling practices. Information in relation to risk was clearly identified. People at risk had clear assessments in place with guidance to enable staff to support people effectively. There were systems in place to check and maintain the safety and suitability of the premises.

This unannounced inspection took place on 20 and 22 February 2018.

Brunswick House Nursing Home is registered to provide nursing and residential care for up to 46 people. Accommodation is provided in one adapted building. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Brunswick House is for older people who may be living with dementia. Care is provided on a long-term or short-term basis, with some people admitted for respite or further assessment on discharge from hospital. At the time of this inspection 42 people were living at the home.

Accommodation at Brunswick House is provided over three floors with bedrooms located on the ground, first and second floors. All floors were wheelchair accessible, with upper floors being accessed via the lift or stairs. Most bedrooms had en-suite facilities and adapted communal bathrooms were available to all. Lounge / dining rooms were located on the ground and first floor. A small garden was accessible from the conservatory / dining area on the ground floor.

Brunswick House Nursing Home was last inspected in April 2016. At this inspection, the home was rated “Requires Improvement” in the Safe domain, as minor improvements were needed in records relating to medicines management. No breaches of regulations were identified. Brunswick House was rated Good overall at this inspection and an action plan was not required.

This inspection was brought forward in response to concerns raised to us in February 2018. This information suggested required standards may not be being met. We therefore wanted to review the care and treatment provided to people.

The service had a registered manager. 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. The registered manager had been in post as manager of the home since 2003. They were registered with CQC as manager of the home in 2011.

During this inspection we identified five breaches of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. Regulation 12 Safe Care and Treatment was not met. Improvements were needed to ensure risks to people were managed safely. This included safe use of equipment, adherence to safe moving and handling practices, ensuring staff followed the guidelines in place and managing people’s medicines safely. There were enough suitable staff to meet people’s needs. The building and equipment were appropriately maintained and people were protected from risks associated with cross infection.

Regulation 13 Safeguarding service users from abuse and improper treatment was not met. People were not always protected from improper treatment as requirements to obtain authorisation to deprive people of their liberty were not always followed.

Regulation 18 Staffing was not met. People were not always supported by staff whose skills and competency to carry out their duties had been suitably checked.

Regulation 9 Person-centred care was not met. People’s needs were not always assessed promptly and detailed care plans were not always in place to ensure people’s needs and preferences would be met. Staff worked well with external health professionals to meet people’s health needs and supported people to eat a suitable diet.

Regulation 17 Good governance was not met. The systems and processes in place to monitor the safety and quality of the services provided to people were not always effective in identifying and addressing shortfalls. Complete records of the care and treatment provided to people had not always been kept. People’s views about the ser

We inspected Brunswick House Nursing Home on the 13 and 15 April 2016. This was an unannounced inspection. Brunswick House is a nursing home for up to 46 older people. 43 people were living at the home at the time of our inspection. A number of people living at the home had been diagnosed with dementia.

We last inspected in April 2014 and found the provider was meeting all of the requirements of the regulations at that time.

There was registered manager in post on the day of our inspection. 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 their relatives were positive about the home, the staff and management. People told us they were safe and looked after well in the home. Staff managed the risks of people’s care and understood their responsibilities to protect people from harm. Mostly people had the assistance they required to take their prescribed medicines. However, nurses did not always maintain an accurate record of people’s prescribed medicines and the medicines they had in stock.

People had access to plenty of food and drink and received a diet which met their needs. Staff ensured their on-going healthcare needs were met.

People told us they enjoyed living at Brunswick House and that it was a friendly, pleasant and lively atmosphere within the home. People also enjoyed the time they spent with each other and staff and carrying out activities. People were offered choices about their day. They told us they felt listened to and able to raise concerns or suggestions.

Staff were supported by a committed registered manager and had access to training, supervision and professional development. They could request further training and development as required. There were enough staff with appropriate skills deployed to meet the needs of people living at the service and support them with activities. Staff spoke positively about the home and the registered manager and told us they valued the continuity of staff.

People and their relatives spoke positively about the management and the service. The registered manager ensured people, their relatives and external healthcare professional’s views were listened to and acted upon. The registered manager involved staff were involved in decisions regarding the home, and respected their views. The registered manager and provider had systems to assess, monitor and improve the quality of service people received at Brunswick House.

A single inspector conducted the inspection and helped to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, from speaking with people who use the service and a relative, from speaking with the staff supporting them and from looking at records. We spoke with seven people who lived in the home although they did not all comment on the service provided. One person told us “it is really nice here, I like it.”

If you would like to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. There were safeguarding procedures and staff received training so that they understood how to safeguard the people they supported. When there had been concerns these were reported appropriately to the local safeguarding team for investigation.

Each person had a series of risk assessments which included the action that was needed to reduce risk and keep people safe. There were also general risk assessments and risk management plans so that the people who lived in the home, staff and visitors were kept safe.

There were systems to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, and investigations. This reduced the risks to people and helped the service to improve continually.

The home had policies and procedures about the Mental Capacity Act and Deprivation of Liberty Safeguards and applications had been made when necessary. Relevant staff had been trained to understand when an application should be made, and about how to submit one. This meant that people would be safeguarded as required.

The home looked safe, clean and hygienic. We saw hand washing facilities and hand gel for staff and visitors. Staff wore plastic aprons and gloves when giving personal care and when serving food. These measures helped to control the spread of infection.

We saw that there were enough staff so that they were not rushed and could respond to people calmly. This helped to make sure that people’s needs were always met. Before staff were employed they had thorough recruitment checks to make sure they were suitable to work with people. Staff received a range of training and most of them had relevant qualifications so that they had the right skills to support people and keep them safe.

A senior manager visited once a month to monitor the quality of service and make sure that practice was safe. There was an enclosed rear garden where people could walk about safely.

Is the service effective?

People’s health and care needs were assessed with them and they had signed a record to show that they consented to them. Information about people's previous lives and their likes and dislikes were recorded in their plans. People told us that the service was flexible to meet the needs. For example, they could get up and go to bed when they wanted and stay in their rooms or go to the lounge. One person said that it was "free and easy here, there are no rules, you can do what you like." When we looked at the care plans we saw that they were regularly reviewed so that they reflected people's current needs.

There was a quiet lounge so that people could have visitors in private away from their bedrooms. We saw that visiting times were flexible and relatives were visiting at different times of the day.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. A relative told us that the care was very good. People told us that the staff always asked them what they would like before giving care or support. One person said. "They look after me really well." Another person said. "The staff are all very good."

People’s relatives, staff and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in line with people’s wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly. The home had an activity co-ordinator. Staff took care to find out what each person was interested in so that they could provide activities that suited their needs.

People’s relatives knew how to make a complaint if they were unhappy. There had been only one recent complaint. We looked at how this had been dealt with, and found that the response had been open, thorough, and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

There were surveys to obtain people’s views and action was taken in response to comments.

Is the service well-led?

The service worked with other agencies such as the social care commissioners, district nurse and GP to make sure people received their care in a joined up way. The service has notified CQC of incidents as required.

The service had a quality assurance system. We saw records, which showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff we spoke with were clear about their roles and responsibilities. The manager told us that the senior managers in the organisation provided good support and direction.

We visited Brunswick House as concerns had been raised with us. We observed what people and staff were doing early one morning before the night staff went off duty and asked people how they had started their day. We spoke to the day and night care and nursing staff, the cook and the registered manager. We found that few people were up and dressed and staff told us that they were given a choice of when to get up. Generally the day staff were giving personal care after people had their breakfast. One person described their personal care that morning and appeared satisfied it was what they wanted.

We observed staff treating people with kindness and respect. There was sufficient staff available to meet people’s needs. During staff handover report there was a time when one floor had no staff for a while but we observed people were safe. We also observed staff appropriately using personal protective equipment while completing personal care to promote infection control.

There was a linen cupboard on each upper floor and both had been left open when they should be locked shut to prevent a fire risk. We have informed Gloucestershire Fire and Rescue Service.

People we spoke with told us they felt well looked after and they had no concerns. We did not speak at length to people at this visit as we were following up on compliance actions issued at the last visit.

When we visited the service there were 46 people accommodated. We spoke with eight people, two relatives, two friends, three care staff, two nursing staff including the deputy manager, a healthcare professional, the activity organiser, a cook and the registered manager. People told us, "I am content here", "the staff are very kind, I am comfortable but I cant walk yet", "I am well looked after they treat me good" and "they are always kind to me, I don't want to leave here".

People had detailed plans of care and support from healthcare professionals to ensure their health and welfare needs were met. We found that many people felt safe in the home according to the survey results and that the staff were trained to identify any abuse and help prevent it. The staff were well trained and supported and had regular supervison and annual appraisals.

The manager ensured that systems in the home were audited frequently and that action was taken when required.