Bryher Court Nursing Home is registered to provide nursing care for up to 45 older people. There were 24 people living at Bryher Court at the time of the inspection. People required a range of care and support in relation to living with memory loss, dementia, nursing and personal care needs. Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two lifts. This was an unannounced inspection which took place on 23 October 2017.

In March 2016 and December 2016 the overall rating for this service was Inadequate and we took enforcement action against the provider and placed the service into Special Measures. Special Measures means a service is kept under review and if needed urgent enforcement action can be taken. The local authority put a restriction on admissions to prevent the service from admitting people until improvements were made. On the 3 and 4 July 2017 we inspected to see if improvements had taken place. The service was rated as Requires Improvement with enforcement action still in place whilst we continued to monitor the service to ensure that improvements continued and became part of the integral systems and processes. At this inspection we found improvements had been made and we have withdrawn the enforcement action previously issued. The provider is now meeting all regulations. We will continue to monitor the service to ensure this level of service is maintained.

The registered manager had left employment at the home but was currently still registered with CQC. The deputy manager had been acting as manager supported by a consultant employed by the provider and the provider, who was present at the home on an almost daily basis. A new manager had been recruited and they had started work the week prior to this inspection. We were told by the provider the newly recruited manager would be registering with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run.

Documentation had been greatly improved with new care plan formats introduced. Care plans were detailed and person centred. Staff had information that enabled them to provide support in line with people’s wishes. Personal and environmental risk assessments took place to ensure people’s safety was maintained. These included risks assessments for people’s specific individual risks and regular maintenance and safety checks for services and equipment. Monitoring and documentation of accidents, incidents and falls was robust. Staff had a good understanding of safeguarding and were able to tell us how they would report a safeguarding concern.

There were systems to assess quality and identify any potential improvements to the service. This included a robust programme of audits completed on a regular basis. All audits included analysis and actions and had been signed and dated when actions had been addressed. Safe medicine procedures made sure people received their medicines consistently and safely. Systems were in place to ensure medicines were ordered, stored and disposed of appropriately. People’s nutrition and health was monitored. Meal choices were available and we received good feedback regarding the meals provided. People's weights were monitored and any changes reported.

Relatives felt that communication was good and they were always contacted if needed.

There was a complaints policy and procedure at the home. People were aware how to raise any complaints or concerns and told us they would be happy to do this if needed. Staff told us they supported people to discuss any issues.

People were supported by staff who were kind and caring. Staff respected people's dignity and right to privacy and knew people well. People were encouraged to

Bryher Court Nursing Home is registered to provide nursing care for up to 45 older people. There were 27 people living at Bryher Court at the time of the inspection. People required a range of care and support in relation to living with memory loss, dementia, nursing and personal care needs. Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two lifts. This was an unannounced inspection which took place on 3 and 4 July 2017.

At the previous comprehensive inspection in March 2016 the overall rating for this service was Inadequate. Six breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified and we took enforcement action against the provider and we placed the service into Special Measures. Special Measures means a service will be kept under review and if needed could be escalated to urgent enforcement action. The local authority put an embargo in place to prevent the service from admitting people until improvements were made.

A further inspection was carried out in December 2016 where we found there was not enough improvement to take the provider out of special measures. We found a number of continued breaches of the of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating remained as inadequate and the service stayed in special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found. This inspection on the 3 and 4 July 2017 was to see what improvements had taken place. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The registered manager had recently left employment at the home but was currently still registered with CQC. The deputy manager was acting as manager supported by a consultant employed by the provider and the provider. 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 and associated regulations about how the service is run.

There were a number of planned improvements and action plans which had not yet been introduced. Therefore we were unable to make a judgment on how effective these were. This is why the rating is Requires Improvement and there is a continued breach on Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. A further timescale has been agreed for these improvements to be made. All areas will be reviewed at the next inspection to ensure they are fully implemented and embedded into practice.

People’s care documentation was not accurate, complete and contemporaneous. Care plans for specific health needs were not detailed and some care plans and records had not been written in a timely manner. Documentation needed to be more robust. Systems to assess and monitor the quality of service needed further improvement. Changes to the way the service was audited were being introduced but were still in their infancy. Some audits had been completed but improvements needed to continue with management and provider oversight to ensure that robust measures are introduced and maintained. We have asked the provider to make improvements in these areas within a set timescale.

There were on-going improvements to ensure the service was safe. Medicines processes had been audited and reviewed. Registered Nurses (RN’s) had competencies assessed to ensure that appropriate standards were maintained. A training programme was now overseen by the administrator who ensured that training was booked and attended by staff when required.

Fire safety training and checks were in place to ensure peoples safety. This included fire drills and equipment available around the building for staff to u

Bryher Court Nursing Home is registered to provide nursing care for up to 45 older people. There were 30 people living at Bryher Court at the time of the inspection. People required a range of care and support in relation to living with memory loss, dementia, nursing and personal care needs.

Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two lifts.

This was an unannounced inspection which took place on 12 and 14 December 2016.

At a comprehensive inspection in March 2016 the overall rating for this service was Inadequate. We placed the service into special measures. Six breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. We found the provider did not have systems in place to continually assess and monitor the quality of service provided. People’s safety had not been maintained as maintenance checks including water safety and risk assessments had not been completed. Electrical testing had not taken place and fire risk assessments and personal emergency evacuation plans (PEEPS) were not completed. New staff had not received an adequate induction; staff competencies including Registered Nurses (RN) had not been completed. Training records had not been updated and mandatory training had not taken place for many staff before they worked unsupervised. People’s care records were not up to date and accurate and did not reflect changes to care needs. Records were task orientated and did not evidence person centred care. Some records were not written respecting people’s privacy and dignity. Medicine procedures needed to be improved to ensure they followed best practice guidelines and people received their medicines in a safe consistent manner.

The provider had not ensured that service users were protected. We issued Warning Notices for Regulation 9, Person-centred care, Regulation 15, Premises and Equipment, Regulation 17, Good Governance and Regulation 18, Staffing. We also identified two further breaches for Regulation 10, Dignity and Respect and Regulation 12, Safe Care and Treatment. The service was rated as inadequate and placed into Special Measures. Special Measures means a service will be kept under review and if needed could be escalated to urgent enforcement action.

The local authority put an embargo in place to prevent the service from admitting people until improvements were made.

The service was required to address the enforcement actions within a designated timescale. This inspection was to check that this had taken place.

The provider sent us an action plan stating they would have addressed the further breaches of regulation by June 2016.

At this inspection we found although improvements had been made in relation to the premises, dignity, respect and person centred care. Areas identified in Warning Notices for Regulation 17 and 18 had not been addressed. This included basic staff training for all staff being kept up to date and staff competency assessments. Some Registered Nurses (RN) did not have any training and competencies completed and had been working unsupervised at night. Training and competency assessments had not been carried out before agency staff worked at Bryher Court, this included RNs who worked unsupervised at night.

Further concerns were identified with regards to Regulation 12 for unsafe medicine procedures. People’s medicines were not stored safely and in line with legal requirements. People did not always receive their medicines as prescribed. There had been medicine errors and some medicines were found with no documentation or information in place to show when or why they had been prescribed. Despite some initial action taken by the provider to monitor and update staff regarding safe medication procedures, this had not been robust or effective. Medicine competencies had taken place for some RNs but not all RNS working unsupervised had been assessed. Competency documentation did not

Bryher Court Nursing Home is registered to provide nursing care for up to 45 older people. There were 38 people living at Bryher Court at the time of the inspection. People required a range of care and support in relation to living with memory loss, dementia, nursing and personal care needs.

Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two passenger lifts.

This was an unannounced inspection which took place on 21, 22 and 23 March 2016.

Bryher Court did not have a registered manager in post. 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.

An acting manager had been appointed and had worked at the service since December 2015. The acting manager told us they would be starting their application to register as manager in the near future.

This inspection took place to follow up on previous breaches identified at the inspection in March 2015. Two regulations which were in breach at the last inspection had been met at this inspection; however, we found four continued breaches and two new further breaches of regulation.

The provider sent us an action plan following the previous inspection telling us the actions they would take to ensure they met regulations. However, we found that these had not been completed to ensure the provider met all registration requirements.

The provider did not have a system in place to continually assess and monitor the quality of service provided. A number of areas identified in the last inspection had not been addressed by the provider to ensure the service met regulations. People’s safety had not been maintained as a number of required checks and risk assessments had not been completed. This included water temperature checks to all areas of the home, legionella risk assessments completed by an appropriately trained professional to access and monitor the risk of water borne infection. Personal appliance testing (PAT) testing was not up to date and some electrical items had no evidence of ever being checked to ensure they did not present a safety or fire risk to people. Fire risk assessments and personal emergency evacuation plans (PEEPS) were not in place for everyone living at Bryher Court. This meant people’s safety had not been maintained.

Although recruitment systems were in place. Induction information for trained staff had not been completed. There was no evidence to show how RNs competencies had been assessed and reviewed. Some staff had not received required ‘in-house’ training before working unsupervised. This included fire training, which had not taken place since 2013. Training records had not been maintained and it was not possible to get a clear picture of when staff had attended or training needed to be updated.

People’s care plans and other care related documentation, including charts and risk assessments had not been completed consistently to ensure information about people was current and accurate. When incidents had occurred these had not been documented in people’s care files to ensure all staff were aware of wounds and treatment required. Care plans currently in place for people did not reflect recent changes to care and people’s daily notes were task orientated, and did not evidence person centred care. Information about people’s care and nutritional needs were displayed on bedroom walls and in public areas. We found that some wording used did not take into consideration people’s privacy or refer to their care needs in a dignified manner.

Medicine procedures needed to be reviewed to ensure they were following best practice guidelines and ensure people received their medicine in a safe and consistent manner; documentation around th

Our inspection team was made up of two adult social care inspectors. We set out to answer our five key questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well lead?

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, our observations during the inspection and the records we looked at. We spoke with 14 service users, a visiting relative, most care staff, each registered nurse and the manager.

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

Is the service safe?

Bryher Court Nursing Home provides accommodation over four floors. Although some areas of the service had recently been redecorated, we found that other areas required repair, renewal and redecoration. One person told us “Some parts of the building look quite knocked about and I don’t like the sticky tape repairs on the stair carpets”. We found that there was no clear oversight or structure to address required work. People were not cared for in a safe and suitable environment because there was insufficient planning and activity to ensure that maintenance and remedial work was carried out. A compliance action has been set for this and the provider must tell us how they plan to improve.

Care plans had recently been reviewed and transferred to a new system. We found that care documents and risk assessments were incomplete for one person and their previous care plan was not available for staff to refer to. An incorrect care plan had been used for a person on respite care and their required risk assessments had not been completed. This meant that people were not protected from the risks of inappropriate or unsafe care because care planning did not identify how people should be safely supported. A compliance action has been set for this and the provider must tell us how they plan to improve.

We found that some records were confusing and difficult to follow because some staff had entered incorrect dates, they were incomplete or there was no clear reason why some records were in place. This meant that these records were not fit for purpose because they did not accurately or fully record the information they were intended to contain. A compliance action has been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty safeguards (DoLS) which apply to care homes. This is where restrictions may be placed on some people to help keep them safe. While no DoLS applications had needed to be submitted, suitable policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

The service had taken appropriate steps to improve the way medicines were managed. Medicines were administered when they should have been, administration charts were checked and people received medicine from staff who had been appropriately trained and competency assessed. One person told us “I’ve never had any problems with getting my medicines, the staff have been very good”.

Is the service effective?

People we spoke with told us they were happy with the care delivered and that their needs had mostly been met. One person told us “On the whole I’m happy with the care I’ve received, but I have needed to speak to staff about how they do a few things when they support me”.

Most people’s health and care needs were initially assessed, but because some care plans were incomplete, it was not possible to confirm that all people’s ongoing needs were being met.

Is the service caring?

People spoke positively about the staff. They said staff were kind and attentive. People said that staff spoke with them respectfully and felt that their privacy and dignity was respected. People’s preferred names were recorded in their care plans and people told us that staff always used these names. We saw that people were dressed in clean clothes appropriate to the care and support they received. Our observation found that staff usually knocked on people’s door before entering their bedroom. However, we discussed with the manager we had seen an isolated occasion during this inspection when this was not the case.

Is the service responsive?

People’s admission needs had been assessed before they moved to Bryher Court Nursing Home. This meant that the service knew the support and facilities needed to meet people’s identified needs. Regular monitoring of people’s health, associated risks and their social needs identified when particular measures were required to help keep people safe. However, we saw that reviews and risk assessment processes did not happen in all cases. This meant that the service could not demonstrate that it was responsive to each person’s individual needs.

Is the service well-led?

We saw that the service had a range of measures in place intended to monitor the quality of the service provided. However, some checks had not taken place. For example, walk around safety checks of the service environment, although in place, were not completed. This meant that there was not an oversight of the quality and safety of the service provided. We found that although the provider visited the service regularly, there was no record of planned, preventative or ongoing building maintenance. Records of quality surveys and minutes of resident and relative meetings, completed in March 2014, were not available to be seen. A compliance action has been set about how the service assessed and monitored the quality of the service it provides. The provider must tell us how they plan to improve.

Staff told us and discussion with them found that they were clear about their roles and responsibilities. During the inspection we received positive feedback form residents about the manager and staff. Staff felt that the manager was hardworking, approachable and supportive and felt that recent changes introduced to the service were positive.

People we spoke with and their visitors told us that care was good at the home and that staff were kind. One visitor told us, “Staff are very kind.” Another person told us “I am well looked after here.” We spoke with two people who stayed in their bedrooms. They told us that it was their choice and they were able to come downstairs if they chose. One person said, “I prefer my own company.”

We saw that staff gained people’s consent before they undertook any care or treatment.

We looked at the systems and processes in place for the safe management of medicines and found that there were shortfalls in the recording of medicines.

Although it was busy at the home we saw that there were sufficient staff to meet the care needs of people who lived there.

We found that staff knew people well, and the care people received was good. However, not all of the records were fully completed.

People we spoke with told us about living at Bryher Court Nursing Home. One person told us “I can choose what I want to do throughout the day”. Another person who had chosen to remain in their room told us “If I want to I just call staff and they will take me wherever I want to go”. We were also told “food is out of this world”. People told us they thought there were enough staff on duty and they never had to wait long for help.

We found that there were plans in place to look after people safely and in a way that met each person's specific needs. We observed staff speak to people with kindness and respect.

Two members of staff that we spoke with told us that the manager was always available and they felt well supported.

We undertook an unannounced inspection of this service on 17 and 18 March 2015. This service provides accommodation, personal and nursing care for up to 45 older people, some of whom have limited mobility, are very frail or receiving end of life care. There were 37 people living at the home at the time of our inspection. Accommodation is arranged over three floors and each person had their own bedroom. Access to the each floor is gained by the main staircase or two lifts, making all areas of the home accessible to people.

This service had a registered manager in post. A registered manager is a person who is 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 last inspected the home in June 2014. We found the provider was in breach of regulations about the care and welfare of people, how some of this information was recorded, aspects of the safety and suitability of the home as well as how they assessed the quality of the service they provided. The provider sent us an action plan telling us what they intended to do make the improvements needed. During this inspection we checked to see if the relevant regulations were now met. We found our previous concerns had been addressed; however, we identified other areas that breached regulations. Some of these breaches were of a similar theme to those identified at our last inspection.

People commented very positively about the care and support received and their experience at Bryher Court. However, the inspection highlighted shortfalls in the following areas that could compromise the safety of people in the service.

Recruitment processes did not ensure that thorough checks took place. These are required to establish why previous employment ended and to inform decisions about the suitability of applicants for their role. Incomplete checks did not promote the principles of a robust recruitment policy or protect the interests of people living at the home.

Staffing levels occasionally did not meet the numbers the home had assessed it needed and processes, intended to safeguard against insufficient staff, were not always effectively implemented. When this occurred, staff told us their shifts felt difficult and hectic to ensure that people’s needs could be met.

Arrangements for the supervision and appraisal of staff were not effective. Although staff supervision took place about concerns, regular supervision and appraisals, intended to monitor the training, on going development and the competence of staff, had lapsed.

Although resolved quickly, checks to ensure the safety of equipment such as the lifts, gas boiler and other gas appliances were out of date. The home could not evidence that they were safe to use and did not present a risk to people living and working at the home.

We made a recommendation that the home review its medication policy to reflect current guidance and amend practices.

The record of complaints and how these were progressed was incomplete and the wording used in the displayed complaints process could be viewed as off-putting. It did not give people confidence that all complaints would be viewed with the same seriousness with which they were made.

Care plans were reviewed regularly, but did not always reflect people’s involvement or the support they may require to ensure they understood and were involved in making and reviewing decisions about their care.

Although care plans recorded changes in people’s condition and support required, they did not always contain sufficient information to enable all staff to understand what had caused the change or if action was required to address the cause. We have identified this as an area for improvement.

A quality monitoring system was in place but was not effective to enable the service to highlight the kind of issues raised within this inspection.

There were also the following areas that did work well. The manager had an understanding of the mental capacity Act 2005, and Deprivation of Liberty safeguards, they understood in what circumstances a person may need to be referred, and when there was a need for best interest meetings to take place. We found the service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and that people’s rights were respected and upheld.

The service records showed that there were low levels of incidents and accidents and these were managed appropriately by staff who sought appropriate action or intervention as needed to keep people safe. Risks were identified and strategies implemented to minimise the level of risk.

People were able to choose their food at each meal time, snacks and drinks were always available. The food was home-cooked, including some home-made biscuits and cakes. People told us they enjoyed their meals, describing them as ‘excellent’ and ‘first class’.

Two activities co-ordinators oversaw the management of activities programmes and entertainment. All staff had a holistic approach and saw it as their responsibility to spend time with people, talk with people, and carry out small acts of kindness such as getting drinks or showing people where to go.

Staff understood how to protect people from the risk of abuse and the action they needed to take to alert managers or other stakeholders if necessary if they suspected abuse to ensure people were safe.

New staff underwent an induction programme and shadowing experienced staff, until they were competent to work on their own. There was a continuous staff training programme, which included courses relevant to the needs of people supported by the home. Most care staff had completed formal qualifications in health and social care or were in the process of studying for these.

The home was led by a registered manager who worked closely with the deputy manager and the staff team. Staff were fully informed about the ethos of the home and its vision and values. They recognised their own roles as important in the whole staff team and there was good team work throughout the inspection. Staff showed respect and valued one another as well as people living at the home.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Which now correspond to 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.