This inspection took place on 6 December 2016 and was unannounced. At the last inspection we rated the service as requires improvement. The provider was not in breach of regulation, however, we identified there were areas to improve. We also said they required a longer term track record of consistent good practice before we rated the service as good. At this inspection we found they had made improvements and have demonstrated a longer track record of good practice.

Brandon House is a nursing home and provides accommodation for up to 42 older people. The service had 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.

People who used the service and their relatives told us the service was safe. Staff had received training to help them understand how to keep people safe. The home looked well maintained, clean and tidy, and checks were carried out to make sure the premises and equipment was safe.

There were sufficient staff with the right skills and experience; several staff told us the staffing arrangements had improved. Appropriate checks were carried out before staff were employed. Medicines were managed safely.

People who used the service and their relatives told us they were happy with the staff who provided care and support. Staff we spoke with said they felt well supported and received training that made sure they knew how to do their job well. They said they understood their role and responsibilities. The registered manager was going to review the induction arrangements to ensure they met recognised guidance. Staff we spoke with understood their responsibilities around how they should support people with decision making. People had good meal experiences, enjoyed the food, and had plenty to eat and drink. Systems were in place that ensured people accessed healthcare services.

People told us they were well cared for and visiting relatives told us the service was caring. We observed care workers supported people in a calm, compassionate and caring way. Staff were cheerful and friendly. When they walked by people they would say “hello” and checked they were ok. When staff assisted people to move and transfer they explained what was happening and reassured them throughout. Staff knew people well, for example, what people liked to do and their family members. We saw one situation where staff were not responsive to a request for support.

People had access to information which kept them informed.

Staff responded to people’s individual needs and delivered personalised care. People’s care plans and other records showed their needs had been assessed and care was usually planned, although there was inconsistency with the level of detail and we saw examples where care plans had not been followed. Action was being taken to improve activities.

The service had developed a 1950's village around the back of the nursing home which people could access. People told us they would talk to staff and management if they had any concerns and complaints had been responded to in a way which resolved the issue where possible to the person’s satisfaction. Several written compliments had been received.

We received positive feedback from people about the registered manager. Several relatives described them as “welcoming” and several staff described them as “supportive”. Resident and relative meetings and staff meetings were held. We saw from meeting minutes that people had opportunity to discuss the service and were informed of planned events. Where people had made suggestions for improvement the provider had responded. At the inspection we reviewed a wide range of audits which had been completed at the service, which were then used to

This inspection took place on 4 August 2015 and was unannounced. This is the third inspection Care Quality Commission (CQC) has carried out since July 2014. In July 2014 the provider was found not to be appropriately respecting and involving people who used the service, ensuring people consented to their care, managing medicines, supporting workers, assessing, planning and delivering safe care, and assessing and monitoring the quality of service provision. We told them they needed to take action to make sure they were not breaching regulations.

In November 2014 we inspected the service again and found they had not made all the required improvements so we took enforcement action. They had improved systems to make sure they met people’s nutritional needs, safeguarded people from abuse and respected and involved people in their care. But they were still not assessing, planning and delivering safe care, supporting staff, ensuring people consented to care, and assessing and monitoring the quality of service provision We served four warning notices. We also set three compliance actions because we found some areas of the home were not clean, there was not enough staff and they were not carrying out robust checks when they recruited workers. In February 2015, we met with the provider and discussed our concerns. They told us they were keen to improve their service and would make the required changes. They sent us a plan of action and told us how they were going to do this. At the inspection in August 2015 we found the provider had taken the necessary action, completed their plan and all legal requirements were met.

Brandon House provides nursing care for up to 42 older people, some of whom maybe living with dementia. At the time of the inspection, the home did not have a registered manager. A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run. The home’s manager had submitted an application to CQC to be registered and this was being processed.

We found people were happy living at the home and felt well cared for. People enjoyed a range of social activities and had good experiences at mealtimes. They were supported to make decisions and received consistent, person centred care and support. People received good support that ensured their health care needs were met.

People told us they felt safe. Staff had a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe. People lived in a safe, clean and homely environment. Medicines were managed consistently and safely.

There were enough staff to keep people safe. Robust recruitment and selection procedures were in place to make sure suitable staff worked with people who used the service. Staff were skilled and experienced to meet people’s needs because they received appropriate training, supervision and appraisal.

The service had good management and leadership. People got opportunity to comment on the quality of service and influence service delivery. The manager and staff operated effective systems that ensured people received safe quality care; however, the provider was not carrying out their own checks to make sure the improved standards were being maintained. People told us they would feel comfortable raising concerns or complaints.

We carried out this inspection 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, speaking with people who used the service, speaking with visitors, speaking with the staff who supported them and from looking at records.

Is the service safe?

The home did not have policies in place in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The policies the home did have in place had not been dated nor did they have a review date. The service had not taken steps to ensure practice was updated through the review of policies. The home was not compliant with DoLS.

The safeguarding policy was followed correctly by staff and all staff received training in this area.

People received an assessment which helped to ensure that the home was able to meet their needs. We saw care records and risk assessments were in place. The care records we looked at were generic and were not person-centred. We saw examples of incorrect information in the care records we looked at. This meant people were at risk of receiving inappropriate care and support.

There was no evidence to show that incidents had been analysed and lessons learnt from any accidents or incidents. This meant the service was not able to identify risks to people and to develop plans to reduce the risks.

In one of the bathrooms we looked at we saw the toilet seat was soiled. In another bathroom, the door wouldn’t close securely and the toilet seat was broken. The interior of the service was in the process of being refurbished and there was a lot of dust in one of the rooms on the dementia unit. Some of the carpeted floors looked dirty and the hardwood floors felt sticky underfoot. The paint on some of the doors and skirting boards had chipped. There was a risk that the chipped areas could harbour germs that could put people’s health at risk.

Is the service effective?

There was no evidence to show people's health and care needs were assessed with them. In the care records we looked at we could find no evidence to show people had been involved in decisions relating to their care. This mean that there was a risk staff were not able to deliver care in a way that supported people because the service had not taken steps to ensure people had been involved in their care planning.

Although visitors we spoke with told us they felt staff cared for their relatives and friends very well, in the training matrix we looked at we saw less than 50% of staff had attended training on key areas such as moving and handling, fire safety, health and safety and Mental Capacity Act 2005. Staff had not been enabled to take part in learning and development that was relevant and appropriate to their role.

Is the service caring?

We found people were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. We observed people looking well dressed.

Staff had a good relationship with people who used the service and it was clear care staff were committed to their role.

During the inspection we observed the call bells were not answered promptly. In some of the rooms we visited we saw that call bells had been placed out of people’s reach. We spoke to one person about this, they told us their bell was always slipping off their bed.

Is the service responsive?

The service carried out annual reviews of the service which included people who used the service and their relatives/friends. The service did not routinely include external agencies in their review. The service did not have a plan of how they would involve people who had difficulty communicating. This meant people were not included in the review of the service and were not given the opportunity to express their views.

The service had held a residents and relatives meeting in the past but we could not see that a meeting had been held recently. The visitors and relatives we spoke with told us they felt the manager listened to their concerns and acted on them.

The service employed an activities coordinator and they told us about the range of activities on offer. On the day of inspection, we saw that none of the people on the dementia unit had been included in the activity planned for that day.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. The care staff confirmed the manager was very supportive. Staff meetings were held so that people could air their views. Staff felt they had been listened to by the manager.

We could see no evidence care staff were offered formal supervision and there was no record of them having had an annual appraisal. The manager told us they did not feel supported by their line manager. They had not received supervision and had not received an annual appraisal.

We spoke with five people who used the service and five members of staff. We reviewed six care plans. The people we spoke with were happy living at Brandon House. One person told us, "I like it here; the staff are very nice to me. I like my room it’s very cosy and I can bring anything into it." Another person said, "The staff are lovely, they get me anything I want and help me choose my meals every day." We saw there were daily activities and people were able to go out.

We saw the communal areas and the bedrooms were clean and free of any malodours. A person who used the service said, "It's always clean, someone is always cleaning." There were effective systems in place to reduce the risk and spread of infection.

During the visit we observed staff supporting people and saw that staff responded promptly to any requests for assistance. Staff told us the staffing levels were sufficient to meet people's needs.

A staff member said, "We try and make Brandon House a friendly place to live in, after all it is their home."

During our visit, we had the opportunity to talk with three people who used the service and to two visitors. People told us they were happy with the care and support they

received.

People said, “I’m very well looked after here. If I need help during the night, they (staff) come and help me straight away”. “The staff are marvellous, each and every one of them”.

One relative told us that they, ‘”Always turned up at any time and we don’t have to stick to visiting hours”. They told us that they were totally confident that staff cared for their relative well. They stated they found the care their relative received was, ‘”Consistent” and that, “Their nails are always clean and their hair is always brushed”. They said they thought that all the staff were, “Honest and accommodating” with them.

People told us that there were always plenty of staff on duty and they felt able to approach staff when they wanted to. Both relatives we spoke with told us that they felt that staff listened to them. They told us that they felt involved in decisions regarding their relatives care.

One person told us that,” They (staff) always treat me with great respect”.

A relative told us that their relative “Had improved a lot since being here, they have started to feed themselves and they don’t need their food liquidising anymore”.

During the visit, we had the opportunity to talk to people living in the home and to some visitors. Overall, people told us they were satisfied with the care and support they received. Some people were complimentary about the staff and described them as “wonderful”, “pleasant” and “sociable”. However, others told us that some staff could be a little impatient at times and said the staff did not always attend to their needs in a timely way. Generally, people had mixed views regarding their involvement with the service. Some told us that they are well informed and felt involved. Others told us that they did not always feel involved, as they had to ask for information.

People who live at the service were satisfied with their care, these are some of the comments they made to us –

“nice carers”

“the carers look after her well”

“it’s good here”

We spoke with relatives who visit the service regularly. Although they were, overall, happy with the care provided they had some frustrations with attention to detail in the care of some of the people living at the service. For example, inconsistent use of denture fixative meaning that people can struggle with their false teeth to eat and talk properly; people not always having a daily shave; wrist splints not being fitted properly.

People who use the service had mixed views about the food, these are some of the comments people made to us –

“food is good and I like it”

“they get you something else if you don’t like what it is”

“sometimes it is cold”

“don’t like the way it is cooked”

On the day of our visit the meal included ‘herby dumplings’ and several people said that they did not like, what they considered, to be highly flavoured foods.

People told us that there was a new chef, this is a weekend chef, and that they had enjoyed the food he cooked.

We saw the lunchtime meal and the food looked well cooked and appetising and most people seemed to be enjoying it. People were able to eat at their own pace and had their pudding served as they finished their main meal.

Staff supported and assisted people as needed, on a one to one basis and were patient. Squash and tea was served over the meal time.

We saw people being offered the chance to wipe their face and hands after the meal.

The inspection was unannounced and took place over two days on 18 and 24 November 2014.

At the last inspection in July 2014 we found the provider was breaching eight regulations. The breaches related to respecting and involving people who use services; consenting to care and treatment; care and welfare of people who used services; meeting nutritional needs; safeguarding people who used services from abuse; management of medicines; supporting workers and assessing and monitoring the quality of service provision. At this inspection we found the provider had made improvements in some areas but they were still in breach of four of the eight regulations. We also found other areas of concern.

Brandon House provides nursing care for up to 42 older people, some of whom maybe living with dementia. The home had 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 and associated Regulations about how the service is run.

Although people told us they felt safe we found this service was not providing consistently safe care. Staffing levels were not adequate to keep people safe. People told us there were not enough staff. People were not adequately supervised and had to wait for support and assistance. The provider did not have effective recruitment and selection procedures in place. Appropriate cleanliness and hygiene standards in the home were not maintained which put people at risk of acquiring infection. People were given their medicines in a safe way. Medicines were kept safely and adequate supplies were maintained to allow continuity of treatment.

Staff were not provided with sufficient supervision and training to ensure they were able to meet people’s needs effectively. Management and staff did not fully understand the requirements or principles of the Mental Capacity Act (2005)(MCA) and Deprivation of Liberty Safeguards (DoLS). Providers are required to submit applications to a ‘Supervisory Body’ for authorisation to restrict people’s liberty but it was clear from the paperwork we reviewed the correct process was not followed so people were not safeguarded. People were offered varied snacks and drinks during the day and enjoyed the food. However, meal experiences were not enjoyable for everyone. Some people had to wait for their meal whereas others received theirs promptly. Staff did not always explain to people what they were having to eat. A range of healthcare professionals were involved in people’s care.

Some people we spoke with were very happy with their care whereas others thought it could improve. We also got a mixed response when we spoke with visitors about the care that was provided. During the inspection we observed good care being provided. Staff were caring and compassionate in their approach.

Aspects of people’s care was not assessed, planned and delivered appropriately. There was not enough information to guide staff on people’s care, treatment and support. The morning routine in one unit was not personalised. A visiting healthcare professional told us the same issues about people’s care and treatment constantly had to be reinforced. People could join in group activities. On the day of the inspection we saw a group enjoying a painting session. People told us they knew who to speak with if they had any concerns.

The provider’s systems to monitor and assess the quality of service provision were not effective. Actions that had been identified to improve the service were not implemented. The provider asked people to comment on the quality of care through surveys but results were not analysed or acted upon. Staff provided positive feedback about the management team. They said the registered manager and general manager were approachable and addressed issues straightaway.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.