Brandreth Lodge Nursing Home

Updated 14 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by 1 inspector.

Service and service type

Brandreth Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Brandreth Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

There was a registered manager in post, however at the time of the inspection they were on holiday. We spoke with the deputy manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 26 July 2023 and ended on 27 July 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people that used the service and 2 relatives. We spoke with 10 members of staff including the deputy manager, care staff, domestic staff and kitchen staff.

We looked at a range of documents including 4 people’s risk assessments and care plans, and their medicine records. We looked at policies and procedures, audits and health and safety certificates. We looked at 3 staff recruitment files, rotas and training records.

Updated 14 September 2023

About the service

Brandreth Lodge is a residential care home providing personal care to up to 24 people. The service provides support to older people. At the time of our inspection there were 16 people using the service. The home is set over 2 floors and had good sized communal areas and gardens for people to use.

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

Risks to people’s health and safety were not always adequately assessed and mitigated, and changes were required to improve the safe management of medicines.

Improvements were required to the overall governance and risk management of the service; training and staff supervisions were overdue.

People were kept safe from the risk of abuse and the risk of mistakes being repeated was minimised. There were enough staff to care for people and the home was kept clean.

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.

We found a positive culture and the service had a ‘homely’ atmosphere. Staff enjoyed their jobs and said they had good support from the management.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 September 2021) and there was a breach of regulation in relation to assessing, managing and monitoring risk. At this inspection we found the provider remained in breach of regulations.

Why we inspected

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.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to assessing risk, managing medicines, and governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.