Brabourne Care Centre

Brabourne Care Centre is a residential care home providing personal and nursing care to 58 people older people, some of whom are living with dementia. The service can support up to 82 people. The service is purpose built with three separate wings over three floors each of which has separate adapted facilities. One of the wings provides care to people living with dementia.

People’s experience of using this service and what we found

People told us they were happy and felt safe living at Brabourne Care Centre. However, we found that medicines management was not always safe. Staff did not document where pain patches were applied, creams had not been dated on opening and medicines stock numbers did not match those on the medicines administration records. Guidance was not always in place for staff to follow to inform them of how best to support people with risks to health, such as skin breakdown. This was implemented on the day of the inspection.

Audits and checks were completed regularly however, they failed to identify issues with medicines and care plans. The quality lead was in the process of reviewing and updating all care plans and risk assessments, however there was no priority to review the highest risks to people. Following the inspection, the registered manager sent us an improvement plan detailing how they planned to review all risk assessments, alongside a full audit of medicines and improvements to implement.

When accidents and incidents occurred, these were analysed by staff and action taken to mitigate risks to people. People were safeguarded from the risk of abuse. Staff had received training in safeguarding people. People were supported by enough staff and were supported by regular agency staff when needed. The service was clean and well maintained.

There was a positive culture within the service. We observed positive, kind interactions between people and staff. Staff worked with external healthcare professionals to ensure people received joined up care. People’s opinions on the service were sought and staff shared information with people and relatives.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection

The last rating for this service was good (published 29 August 2018).

Why we inspected

We received concerns in relation to the quality of care and staffing levels. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. The registered manager took action to address the shortfalls we identified and has implemented improvements. We will check this on our next inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Brabourne Care Centre on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to medicines management at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Brabourne Care Centre 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. Brabourne Care Centre is registered to provide accommodation, nursing and personal care for up to 82 older people. There were 72 people using the service during our inspection, 15 people were using the service for a short stay.

The service has three units over three floors: Edinburgh and Maxwell on the ground floor has capacity for 30 people; Eastwell and Ramsey, on the first floor has capacity for 29 people; and Mountbatten on the second floor has capacity for 23 people.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in April 2017, the service was rated 'Requires Improvement', with three breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued requirement notices relating to safe care and treatment, person centred care and good governance. We asked the provider to take action and they sent us an action plan. The provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found improvements had been made, and the previous breaches had been met.

At our previous inspection we found that there was not sufficient, clear guidance for staff to follow when supporting people with catheter care, health conditions such as epilepsy and people's personal emergency evacuation plans (PEEPs) did not contain the necessary level of detail to ensure staff were able to assist people to leave the service safely in the event of a fire. At this inspection we found that overall these issues had been addressed and improvements had been made. PEEPs for most people had been reviewed and contained clear guidance on how staff should support people to leave in an emergency. We found that PEEP’s for some people who were staying for a short period of time did not always contain sufficient clear guidance. We discussed this with the registered manager, who told us they would ensure these were all reviewed. This is an area for ongoing improvement.

At our last inspection people’s care records did not consistently reflect the care they were receiving. At this inspection, improvements had been made. People’s care plans had been reviewed and now contained clear, specific guidance for staff. They also contained more person-centred detail. They contained clear information regarding how to support people with specific tasks, such as washing or showering and how they liked to be supported to go to bed.

At the previous inspection audits designed to measure the quality and safety of the service were not sufficiently robust. At this inspection we found improvements had been made. The registered manager told us they had begun to document the audits they completed. We reviewed audits of medication, PEEPs, and moving and handling assessments.

Medicines were managed safely and there were enough nurses and care staff on duty. Suitable provision had been made to prevent and control infection. Lessons had been learned when things had gone wrong. Equipment and the premises received regular checks and servicing to ensure it was safe. The registered manager monitored incidents and accidents to make sure the care provided was safe. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do.

People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the provider or outside agencies if needed.

Staff had completed induction training when they first started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people's needs. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people's care and lives.

There were suitable arrangements for managing complaints and provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death. Staff worked well together and ensured that clear communication between themselves and external health professionals took place; for example, with care managers, commissioner GP's and district nurses.

Staff encouraged people to be involved and feel included in their environment. People were offered varied activities and participated in social activities. Staff knew people and their support needs well. Staff were caring, kind and respected people's privacy and dignity. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff. People were given emotional support when it was needed and they had been supported to be actively involved in making decisions about their care as far as possible. This included them having access to lay advocates if necessary. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. Confidential information was kept private.

People were encouraged to eat and drink enough and were offered choices around their meals and hydration needs. Staff understood people's likes and dislikes and dietary requirements and promoted people to eat a healthy diet. There was mixed feedback about the food people were offered, we made a recommendation about this. People received care that achieved effective outcomes in line with national guidance. Appropriate arrangements had been made to help people receive coordinated care when they moved between different services. People had been supported to access healthcare services when necessary. Suitable arrangements had been made to obtain people’s consent to the care and treatment they received. The accommodation was adapted, designed and decorated to meet people’s needs and expectations.

Quality assurance audits were carried out to identify any shortfalls within the service and how the service could improve. Action was taken to implement improvements. Accidents and incidents were monitored and reviewed. Actions were taken to reduce the risk of reoccurrence. Staff told us that the service was well led and that they felt supported by the manager to make sure they could support and care for people safely and effectively. Staff said they could go to the manager at any time and they would be listened to.

Brabourne Care Centre provides accommodation and nursing care for up to 82 older people. The premises are a purpose-built detached building, which is situated in a residential area of Ashford, near to the town and associated amenities. The service has three units on three floors: Edinburgh Maxwell on the ground floor has capacity for 30 people; Eastwell Ramsey, on the first floor has capacity for 28 people; and Mount Batton on the second floor has capacity for 23 people. There were 69 people living at the service at the time of the inspection.

The service is run by a registered manager, who was present on the days of the inspection visit. 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.

Risk to people had generally been assessed but not all risks had been managed with sufficient, individual guidelines in place for staff to follow. Care plans, risk assessments and guidance were in place but did not always provide staff with detailed and up to date guidance, so that they could support people in an individual way. Assessed risks to people's health, such as monitoring food and fluid intake or pressure reliving equipment were not consistently managed effectively.

There were enough staff on duty and they had received relevant training and supervision to help them carry out their roles effectively. Staff were observed putting their training into practice in a safe way. There was no use of a formal dependency tool to enable to registered manager to assure themselves that staffing levels remained adequate. Most recruitment files contained all the required information about staff, but the minority needed further detail about past employment.

A number of audits and checks were carried out each month by the registered manager or a nominated person, but they had not always been effective in identifying the shortfalls highlighted during our inspection.

Staff knew how to keep people safe from abuse and neglect and the manager referred any incidents to the local safeguarding authority as appropriate. Incidents and accidents had been properly recorded and preventative actions taken. Fire safety had been addressed through training, drills and alarm testing. Maintenance had been carried out promptly when repairs were needed.

Medicines were managed safely. People received their medicines safely and when they needed them. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and appropriate referrals were made when required.

Staff encouraged people to be involved and feel included in their environment. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff. People's privacy and dignity was respected.

Staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives.

The registered manager completed a detailed assessment of people’s needs prior to moving into the service. This gave them an opportunity to know people and their support needs and to answer any questions or queries people of their relatives had.

Activities staff offered people a range of one to one and group activities that met their needs and preferences.

Complaints had been properly documented, and recorded whether complainants were satisfied with the responses given. People and relatives said they knew how to complain if necessary and that the registered manager was approachable.

People had a choice of meals, snacks and drinks, and could choose where they would like to eat. Many people chose to eat their meals in their own rooms. Staff encouraged people to eat their meals and gave assistance to those that required it.

Staff understood the principles of the Mental Capacity Act and knew how to support people who were not able to make their own decisions. People's rights were protected.

Staff reported that they were clear about their roles and felt well supported by the registered manager and the unit managers for each floor. Staff said there was good communication. Feedback was sought from people, relatives and professionals. This was collated and reviewed by the registered manager.

We have made the following recommendations:

We recommend that the provider considers using a recruitment checklist to ensure that all areas are addressed for every applicant, in line with Regulations.

We recommend that the registered manager introduces a formal dependency assessment tool in order to assure themselves that staffing levels are sufficient to meet people’s needs.

We recommend that the service looks to develop end of life care plans into person centred documents; detailing people’s preferences in a holistic manner.

We recommend the provider seeks feedback around people’s preferences for weekend activities.

We found three of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

The visit lasted over two hours, during which time we inspected medication storage on each floor; talked with nursing staff; and examined medication administration records and policies and procedures.

We found that the manager had implemented new medication policies and procedures which reflected local practice. Action had been taken to meet the regulation, and we found that the service was compliant with the management of medicines.

People we spoke with who lived in the home told us that they were happy with the care and support they received. Comments included 'the carer's are good; they're always helpful' and 'the staff are very good' and 'the staff are lovely; nothing seems too much trouble'. A visitor told us that they had looked at several homes for their relative and said 'I have made a good choice; it's very homely'.

People told us that they were supported to make their own day-to-day decisions and were involved in how their care and support was provided.

We found that care plans contained details about people's daily routines, their care needs and the support they required from staff. Risk assessments were in place to identify and minimise risks as far as possible for people who lived in the home.

We found that the home had arrangements in place to protect people from the risk of abuse and people said that they felt safe. One person told us 'I feel safe here and that's important to me'.

We found that the home did not always have appropriate arrangements in place to manage medicines safely to help ensure that people were protected from the risks associated with medicines.

We found that there were enough suitably trained and qualified staff to support people's needs. One member of staff told us 'it's a good team here; a lot of us have been here a long time and get on well'.

People told us that they were treated with dignity and respect and felt they were well cared for. Comments included, 'Everyone seems to know what they are doing', 'When I came in I was very poorly but I can feel that I have improved' and 'I have no complaints'.

We observed that staff respected people's dignity by ensuring that they closed doors when they delivered personal care. We found that staff knew about people's individual likes, dislikes and preferences and we observed positive interactions between staff and the people who lived in the home.

We saw that staff were trained and supervised appropriately to enable them to deliver safe and effective care.

Staff knew who to report to if they had any concerns about the safety of the people who used the service.

There were systems in place to monitor and assess the quality of the service provided.