Archived: The Brake Manor

We undertook this comprehensive inspection of the service as we had received concerns in respect of the care and welfare of people using the service. The concerns raised were that staff did not know what a person’s needs were when ambulance staff requested the information. Also, that where people were at risk from skin damage, staff were not supporting them as instructed in their care plan to minimise this risk.

The provider for this location is registered under the legal entity of Morleigh Limited which is responsible for a group of nursing and residential care homes.

The Brake Manor is a care home which provides accommodation for up to 26 people who require residential care. At the time of the inspection 25 people were living at the service. Some people were living with dementia. The Brake Manor is a three story house set in an elevated position in its own grounds. The service had a range of aids and adaptation in place to meet the needs of people living there.

The service is required to have 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. The Brake Manor had two registered managers in post until September 2016 when one left. The current registered manager had been managing the service on a part time basis three days a week. The registered manager was not available throughout the inspection although they had been made aware of our presence in the service and did visit the service on the day. At the time of this inspection a newly recruited full time manager had been in post for eight days.

Systems and processes to ensure good governance were not being effectively operated. Records relating to managing the health and care needs for people were not always being updated or completed by staff. People’s fluid intake was not being recorded as instructed in the care plan. There were gaps in records to demonstrate people had been repositioned regularly to prevent pressure sores.

Medicines were not being managed safely. There had been no audit of the medicines system since July 2016. The medicines trolley was dirty and disorganised. There was no evidence of stock rotation. Medicines were being used when the use by date had expired. There were gaps in the records of when creams had been applied and they were not consistently signed as given. Medicines were not being returned to the pharmacist as required. Medicines requiring stricter control were not being managed safely. The level of stock of these medicines did not reconcile with the records. We found one person was not receiving their medicine as prescribed. There were regular errors in recording medicines which required stricter controls.

Records to show when people had been repositioned due to the risk of pressure damage to their skin, were not always taking place or being recorded. One person who had been identified as requiring repositioning and had no record to show this had occurred throughout the day of the inspection. This person’s care records had not been updated since May 2016 and therefore staff did not have the accurate information to enable them to deliver safe and effective care. Staff were relying on daily information from the manager. Another person required regular re-positioning. The associated records were not clear. They did not record the time or frequency of change. They did not show what position the person had been in prior to the change and what position they were in when the staff had completed the change. This meant the information could not be relied upon and we were unable to establish if people were receiving the care and support required to protect them from identified risk.

Records relating to managing the health and care needs for people were not always being updated or completed by staff. People’s fluid intake was not being recorded as instructed in the care plan. One person’s health had been deteriorating for some time and a professional told us they had only recently been made aware of this person’s needs in order to carry out a health assessment. The person had experienced a weight loss of 10kgs in the period August 2016 to October 2016. A record of the person’s food and fluid had been put in place to allow staff to monitor if they were getting enough to eat and drink. Fluid records did not show the minimum daily amounts the person should be consuming. This meant staff would be unaware if the person’s intake was enough to maintain their well-being. Daily fluids recorded were not totalled or reviewed. Where people were at risk of losing weight due to a poor appetite or being unable to eat independently they had their weight recorded. However, these weight records were not being reviewed regularly to ensure that any loss of weight was identified and action was taken to address the concern. This meant care and support was not being monitored effectively.

Information in care plans was not always accurate because they had not been reviewed or updated. For example a person had recently been discharged from hospital back to the service and their needs had changed. Staff told us they had been updated about the person’s needs verbally by the manager. However the person’s care plan was last reviewed in May 2016 and did not reflect their current needs.

The service did not have robust recruitment procedures in place. We found staff were starting work in the service before the organisation had received satisfactory Disclose and Barring Service (DBS) checks. In one instance an employee had no record of the date they started working in the service or whether a satisfactory Disclosure and Barring Service (DBS) check was in place at the time the staff member started work. These are used to help ensure staff are suitable to work in the care sector. In two other instances recruitment files showed one person had started working at the service ten days before a completed DBS check had been received and another twenty-one days before a satisfactory DBS check had been received. The failure to complete necessary checks before allowing staff to provide care exposed people to unnecessary risk.

The environment was not being suitably maintained and there was a general air of neglect. There was evidence of some water damage to the ceiling of a bedroom on the third floor. This room also had the top drawer missing from a chest of drawers. A room on the first floor had been a bathroom. The bath had been removed although the toilet was still operational in this room. There was no floor covering for this room. Two hoists were also being stored in this room and there was a sliding door with no lock. The dignity of people using this toilet was therefore not maintained.

There was a lack of signage which would support people to move around the service independently and recognise bathroom, lounge and dining areas as well as their own rooms. This did not support the needs of people who were living with dementia, and needed prompts to help them to recognise their surroundings.

Systems for recording daily records were not robust. This was because staff removed all care plans from the office and completed the daily logs in the lounge area. However, there were occasions when staff needed to respond to call bells etc. This meant staff sometimes had limited time to complete the daily logs. In some instances staff told us they verbally passed on information to their colleagues about an event and relied on the staff member to record this.

Staff were not always being regularly supported in their role. Staff told us that, due to recent changes in managers, supervision had lapsed. Two staff files did not have any supervision records in place. Staff files were loose leaf resulting in information being difficult to find. There was a supervision matrix in place. It showed the previous manager and four of the care staff had not received supervision at all during 2016. This meant not all staff were receiving the level of support they needed to help them carry out their role and develop their learning.

Staff were caring but were not always available to people in lounge areas for any length of time to provide meaningful support. For example, two people without mobility in reclining lounge chairs spent most of the morning sleeping. They remained in the chairs when being supported with their lunch. There was little interaction seen between them and the staff members on duty. Staff were respectful and sensitive when speaking with them but there were periods of time when they were on their own without any environmental stimulation other than music playing or television. Neither seemed particularly interested in these pastimes.

People had mixed views about meals provided by the service. Some people told us they liked the food and others said it could be improved. In general we found that the quality of food was adequate though not of a high quality. Comments included, “It’s not been as good as usual today” and “I have changed my mind and had the alternative.” Other people told us they were not happy with the food in general. Comments included, “It’s

This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Brake Manor on our website at www.cqc.org.uk. The service was last inspected in November 2014; we had no concerns at that time.

The Brake Manor is a care home which is registered to provide personal care for up to a maximum of 26 older people, some of whom had a diagnosis of dementia. On the day of the inspection there were 23 people living in the service.

There was a registered manager in post who was responsible for the day-to-day running of the service. 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.

At this inspection we did not find any evidence to substantiate the concerns raised. When we arrived at 9.30am in the morning most people were up, eating their breakfast and staff were assisting other people to get up. There was an unrushed, relaxed atmosphere and staff were working with people at their pace. It was clear from speaking with people and staff that people had chosen when they got up and went to bed.

People’s individual care plans recorded their preferred choices and routines. We observed staff asking people for their consent before delivering care. People were involved in making choices about how they wanted to live their life and spend their time.

Care records were up to date, had been regularly reviewed, and accurately reflected people’s care and support needs. Staff supported people with their personal care needs and people looked clean and well cared for.

The building was clean, well maintained and free from any unpleasant odours. There was hot water, set to the correct temperature, in the sinks in people’s rooms and in shared bathrooms. The registered manager advised us that a few weeks prior to our visit the rooms on the top floor had been without hot water for two days due to a fault with the boiler. Once the fault was repaired hot water was restored to these rooms.

Staff told us there were plentiful supplies of suitable gloves for them to use and they had access to hand sanitiser. This meant people were protected from the risk of infection because there were systems in place to prevent and control infection.

We found people had access to appropriate moving and handing equipment. The registered manager sought advice from healthcare professionals, such as community nurses and occupational therapists, to ensure people were assessed for the right equipment.

Staff supported people to maintain a balanced diet appropriate to their dietary needs and preferences. People were able to choose where they wanted to eat their meals, in either one of the lounges, dining room or in their bedroom. People had a choice of meals and had access to snacks throughout the day, evening and during the night. One person told us, “Yes the meals are very, very good. I like a hot drink before I go to bed and a biscuit or something.”

People who were able to express a view of the service told us they felt safe living there. Comments included, “Not sure how long I have been here, but I like it” and “I am very happy here, this is my home.” We observed people were relaxed and at ease with staff, and when they needed help or support they turned to staff without hesitation.

People had a good relationship with staff and staff interacted with people in a caring and respectful manner. One person told us, “You can always talk to staff and they will stop and listen to you. I can’t fault them.”

There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes.

We gathered evidence against the outcomes we inspected to help answer our five key questions: is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Overall we found The Brake Manor to be safe.

During this inspection we spoke with four people living in the home, two visiting relatives, one visiting health worker and four of the care staff on duty.

We saw that people were treated with dignity and respect by the staff. People we spoke with told us 'can't fault it [the home]' and 'I like it here '.

At our inspection on 17 June 2014 we found people's needs were not always met because care records did not accurately reflect their current needs. Vital information for staff to follow was not recorded in care records, which meant staff did not always have sufficient information to meet people's needs. At this inspection we found improvements had been made to people's care plans and these had been updated to mostly reflect people's needs.

At our inspection on 17 June 2014 we found there were not always enough staff on duty to meet people's needs. At this inspection we spent time in the communal areas and observed interaction with people to check if there were enough staff to safely meet people's needs. We found there were adequate numbers of qualified, skilled and experienced staff to meet people's needs.

Is the service effective?

Overall we did not find The Brake Manor to be effective.

People's health and care needs were assessed and specialist dietary, mobility and equipment needs had been identified in care plans where required. Staff we spoke with showed they understood people's needs.

At our inspection on 17 June 2014 we found where people lacked capacity, assessments of their ability to make specific decisions about their care had not been completed. At this inspection we found people's capacity to make daily decisions had been assessed. Care plans detailed the daily decisions people could make and how staff could support them to make their own decisions. This meant staff understood how to support people to make decisions about their care because areas where they could make decisions were identified.

At our inspection on 17 June 2014 we found care plans did not give staff sufficient information for them to effectively meet the needs of people who had complex behavioural needs. At this inspection we found where people could display challenging behaviour care plans had not been updated to give staff guidance about how to respond to people when their behaviour became challenging.

Is the service caring?

Overall we found The Brake Manor to be caring.

We observed people in the main lounge and dining room area throughout the six hours of the inspection. We saw staff interaction with people was caring and considerate.

People we spoke with told us staff were kind and caring. Relatives we spoke with also told us staff were attentive to people's needs and they were confident people living in the home were well cared for.

Is the service responsive?

Overall we found The Brake Manor to be responsive.

The Brake Manor gave clear information to people about how to complain. The home had not received any complaints since our last visit in June 2014. Relatives we spoke with told us whenever they raised any concerns these were listened to and dealt with promptly. This meant that any concerns were dealt with quickly and resolved without the need to formally complain.

We spoke with a visiting health worker who told us the home responded well to people's changing needs and reported any health concerns to them in an appropriate and timely manner.

The home had an activities co-ordinator who arranged group activities such as arts and crafts, singing sessions and quizzes as well as individual one-to-one activities with some people.

Is the service well-led?

Overall we did not find The Brake Manor to be well-led.

At our inspection on 17 June we found care plans were not robustly reviewed and did not give staff clear guidance to ensure people's needs were met safely and effectively. This was particularly in relation to people who had complex communication or mobility needs.

At this inspection we found care plans had been reviewed and in most areas gave staff guidance about how to provide care that met people's needs. However, we found staff were still not given clear guidance and direction about how to manage and understand people who had complex behavioural needs.

We found the provider had not always sought guidance from appropriate professionals to assess people's behavioural needs and provide knowledge based advice for staff about how to meet those needs in practice.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Overall we did not find The Brake Manor to be safe.

During our inspection we spoke with eight people living in the home and two visiting relatives. People told us they felt safe and their privacy and dignity was respected. Comments from people included, 'you couldn't find a better home', 'I feel safe here', 'It's lovely here, couldn't be better, I'm happy' and 'they {staff} always knock on my door before entering'.

However, people's needs were not always met because care records did not accurately reflect their current needs. Vital information for staff to follow was not recorded in care records, which meant staff did always have sufficient information to met people's needs.

There were not enough staff on duty to meet the needs of the people living at the home. We have asked the provider to tell us what actions they intend to take to meet the requirements of the law in relation to people's care and staffing levels.

Is the service effective?

Overall we did not find The Brake Manor to be effective.

During our inspection we observed staff caring for people. It was clear from our

observations and from speaking with people that staff had an understanding of people's needs.

We found the service had obtained consent from people, or their representatives, and acted in accordance with their wishes. However, we found the provider was not meeting the requirements of the Mental Capacity Act (MCA). This was because where people lacked capacity, assessments of their ability to be involved in and to make specific decisions about their care had not been completed. We have asked the provider to tell us what actions they intend to take to meet the requirements of the law in relation to MCA.

People's health and care needs were assessed. However, assessments of people's mobility and equipment needs had not been updated and did not accurately reflect the care being provided.

We identified during this inspection that the low levels of staff on duty impacted on the ability of staff to meet people's needs effectively.

Is the service caring?

Overall we found The Brake Manor to be caring.

During our inspection we spoke with eight people living in the home and observed staff interaction with people. People we spoke with told us staff were caring and attentive to their needs. We observed staff responded to people in a kind and caring manner.

Comments from people about staff included, 'staff are really wonderful' and 'you can't fault the carers'.

Is the service responsive?

Overall we found The Brake Manor to be responsive.

People told us the home had responded when they became unwell and taken appropriate action. One person told us, 'Recently I had heart problems in the middle of the night, it was dealt with quickly, paramedics came and took me to Treliske'.

The home provided group activities such as arts and crafts, singing sessions and quizzes as well as individual one-to-one activities with some people. Most people we spoke with did not express a view about the activities on offer.

Is the service well-led?

Overall we did not find The Brake Manor to be well-led.

The home worked with external health professionals to ensure people's health needs were met. Care files we looked at showed evidence of the home working with GPs, community nurses, community mental health nurses and dieticians.

The provider asked people who used the service, their families and professionals for their views about their care and treatment and used any feedback to improve the service.

However, the provider did not have an effective quality assurance process to monitor how they provided care. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

Care plans were not robustly reviewed and did not give staff clear guidance to ensure people's needs were met safely and effectively. This was particularly in relation to people who had complex communication or mobility needs. The provider had not carried out a needs analysis and risk assessment of people's needs as the basis for deciding on sufficient staffing levels to meet people's needs.

We were shown that there was a robust system in place to order, store and dispense people's prescribed medicines.

People who used the service, and the staff, told us there were not enough staff on duty to meet people's needs.

The care records reflected people's care and support needs and associated risk assessments.

We were shown that there was a robust system in place to order, store and dispense people's prescribed medicines.

People who used the service and staff told us there were enough people on duty to meet people's needs. We looked at three staff files and found they included all the required information.

The training records showed that staff had undertook a variety of training including fire safety, dementia care, safeguarding and medicines management.