We carried out an unannounced comprehensive inspection at Breage House on 14 September 2018. The previous inspection took place on 9 June 2017. At that time, we identified concerns in relation to how some staff approached some of the people they supported, and the staff team dynamics. We also had concerns around staff knowledge and skill in meeting people’s dietary needs. Since that inspection the management team had changed and some staff had left the service. Staff told us they felt more supported by the managers of the service, and with the staff changes this had led to the staff team working more positively together. The catering staff had also changed and staff had all received training in understanding people’s dietary needs. At this inspection we found staff dynamics were no longer impacting on people and that staff had a greater understanding of people’s dietary needs.

At this inspection we found improvements had been made in all the areas identified at the previous inspection. This meant the service had met the breaches of regulation from the last inspection and that the overall rating of the service had changed from Requires Improvement to Good.

We identified some concerns regarding accurate recording of information. For example, some risk assessments were not in place, medicine sheets had gaps, and a lack of formal monitoring regarding accidents and incidents. During the inspection and immediately following the visit the registered manager and Head of Specialist Services put together an action plan and assured us that these would be addressed. Whilst it was acknowledged that this had no direct impact on people’s wellbeing it was an issue in respect of maintaining accurate records. We have made a recommendation regarding this in the Well Led section of the report.

Breage house is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Breage house is one of a number of services in Cornwall which are run by the provider, Keelex 176 Limited. Breage House is a detached home which provides accommodation for up to 14 people who have a learning disability. At the time of the inspection 14 people were living at the service. The registered manager took an active role in the running of the service. They were supported by a core staff team who had worked at the service for some time.

The service had a registered manager in post. 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 care service was established before the introduction of Registering the Right Support and had been developed and designed in line with the values that underpin this and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism, using the service can live as ordinary a life as any citizen.

Some people had limited verbal communication skills so we spent time observing their interactions with staff. The atmosphere at Breage house was calm and friendly. Interactions between staff and people were kind, respectful and supportive. Staff described to us how they worked to support people to make day to day choices and build on their independent living skills. Staff said they were proud to work at Breage house.

The premises were well maintained, pleasant and spacious. People's bedrooms had been decorated and furnished in line with their personal preferences. Risks associated with the environment had been identified and action taken to minimise them.

Care plans reflected people’s needs and pr

We inspected Breage House on the 9 June 2017, the inspection was unannounced. Breage House is one of a number of services in Cornwall which are run by the provider, Keelex 176 Limited. Breage House provides accommodation for up to 16 people who have a learning disability. At the time of the inspection 12 people were living at the service.

At the last inspection, in September 2016, the service was rated Good. At this inspection we identified two breaches of regulation and therefore the service is now rated as Requires Improvement.

This inspection was brought forward as we had received four anonymous concerns about the service. The concerns were in relation to how some staff approached some of the people they supported, and the staff team dynamics. We discussed these areas of concerns with the registered manager, and also spoke with staff members prior to, during and following the inspection.

It is acknowledged that the registered manager had only worked at the service for a few months and was getting to know the people, staff and service. Therefore some staff said they were not sure if they could approach the manager with concerns as their working relationship was developing. This had led to the commission receiving concerns about the service directly.

Eight out of nine care staff that we spoke with during this inspection process, told us relationships between certain members of the staff team were strained. Staff expressed concerns that there were “divides’” between the staff team and were fearful that this could impact on the care provided to the people they supported. Staff had lacked confidence in the service’s management but were hopeful that the appointment of the new registered manager would address these concerns. However, as yet they did not yet feel sufficiently confident to raise concerns directly with the new registered manager. They also hoped that the registered manager would provide a consistent management response to all staff. They felt this would then address the tensions between staff and that all would be treated fairly and be listened too.

Staff were concerned about the quality of food provided, its nutritional value and presentation. We observed at lunchtime that some people were given blended cheese on toast which had been made with brown bread. The presentation of this meal looked unappetising and one person queried the food until a staff member intervened, explained what it was and tasted it them self. The person was then encouraged to eat it. The cook was aware that the presentation of blended meals was unappetising. Due to this the registered manager had purchased some food moulds, which arrived during the inspection, so that this could be addressed.

A cook had recently been employed at the service but had not been provided with appropriate training or guidance on how to prepare food for people’s specific dietary needs. This meant that the meals were not presented in a manner that the person could choose or manage.

We reviewed the service’s menu for the week of our inspection and found that none of the meals were home cooked. The options available were unlikely to provide people with a balanced diet and lacked fresh fruit and vegetables.

We reviewed the kitchen documentation. Documents showed that kitchen had not been regularly cleaned in accordance with the cleaning schedule. The failure to ensure the cleanliness of food preparation areas exposed people to significant risks in relation to cross contamination and infection control.

People’s weight was not able to be monitored as the weighing scales had been moved to another care service. Therefore staff were unable to monitor people’s weight which could highlight potential changes to a person’s health and well-being. The registered manager and deputy manager acknowledged that weighing scales needed to be available at the service to ensure an overview of peoples dietary needs occurs.

We received concerns prior to the inspection about

We inspected Breage house on the 27 September 2016, the inspection was unannounced. Breage house is one of a number of services in Cornwall which are run by the provider, Swallowcourt. Breage House provides person accommodation for people who have a learning disability. At the time of the inspection 14 people were living at the service.

There had been no registered manager in post since October 2015. 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. The present manager had resubmitted a registered manager application to the CQC which was being considered.

At this visit we checked what action the provider had taken in relation to concerns raised during our last inspection in October 2015. At that time we found two breaches of legal requirements related to the service. These were insufficient staffing and although there were appropriate systems in place for the recording of accidents and incidents within the service these had not been used consistently.

We reviewed staffing levels at this inspection and spoke with staff, people and relatives. Staff and relatives told us they felt there were now sufficient staffing levels on duty at all times. We saw from the staff rotas that staffing levels had increased on shift. The numbers of staff were determined by the needs of each individual person for that day. For example if people were to attend activities outside of the service then more staff would be on duty to facilitate the activities. Staff felt there had been a “tremendous improvement” and told us that people’s activities no longer were cancelled due to lack of staff availability.

The service had a staffing calculation system. This assessed people’s dependency needs and the time staff needed to undertake certain tasks for each person. From this the amount of staffing time was then calculated for that person. The manager had recruited new staff so that the staff team had also grown in size. We therefore concluded that the provider had met the shortfalls in relation to the requirements of Regulation 18 as identified in the last inspection report.

We saw documentation which evidenced that all incidents were now recorded and investigated appropriately. All accidents were not only investigated at the service, but were sent to the services head office so that they could be analysed further. Any learning from these incidents were relayed to staff and other interested parties in the persons care, such as health professionals and family members. This meant that future reoccurrence of risks to a person’s safety and wellbeing would be minimised. We therefore concluded that the provider had met the shortfalls in relation to the previous breach.

People were happy and relaxed on the day of the inspection. We saw people moving around their home as they wished, interacting with staff and smiling and laughing. Staff were attentive and available. Staff encouraged people to engage in meaningful activity and spoke with them in a friendly and respectful manner. Staff were knowledgeable about the people they supported and spoke of them with affection.

Staff had high expectations for people and were positive in their attitude to support. Staff were respectful of the fact they were working in the people’s home. The service offered flexible support to people and were able to adapt in order to meet people’s needs and support them as they wanted. For example staff rotas were flexible to allow people to take part in activities which overlapped the default shift patterns. For example if people wanted to go out for the evening this was catered for.

The mangers discussed with us how they were currently reviewing their care plan formats. They had identified th

The service’s registered manager had recently given notice of their intention to resign from their role. The provider had appointed a manager from another of its services to Breage House. The timeliness of this appointment had ensured there was a significant handover period where both managers were present in the home to enable a smooth transition of management responsibilities. The service’s new manager intended to apply to the commission to be registered as the service’s 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.

Two inspectors carried out this unannounced inspection on 3 November 2015. The service was previously inspected on 16 August 2013 when it was found to be fully compliant with the regulations.

The service’s risk assessments had not been regularly updated and did not accurately reflect the methods used by staff to help ensure people’s safety. In addition, where significant incidents had occurred, these incidents had not been appropriately documented and investigated by the services managers.

On the day of our inspection Breage House was short staffed as a result of the recent departure of a number of staff and significant levels of staff sickness. The provider had recognised this issue and made arrangements for additional staff support to be provided. However, these arrangements had not been sufficient to ensure there were enough staff available to meet people needs. Staff reported this had impacted on the quality of support people revived although they believed personal care had not been compromised. In order to resolve the staff shortage at Breage House a recruitment campaign had been launched. This had resulted in the recruitment of four additional staff who were due to begin their induction in the week following our inspection. Although staff told us they had been over stretched they recognised that the provider had acted appropriately to address the current staffing shortages within the service.

People told us the staff at Breage House were; “good”, “very nice” and “very supportive.” While people’s relatives commented, “I am quite confident that they are looking after [my relative]” and, “they [staff] do a very good job, they put a lot of effort in to look after [my relative].”We found that staff training needs were well managed and that all new members of staff received appropriate induction training in accordance with the requirements of the care certificate. Staff told us they were well supported by the both the service’s managers and the provider’s senior management team. We saw staff had received regular supervision and annual performance appraisals and that staff meetings were held regularly.

We saw people were relaxed, happy and comfortable at Breage House and people’s relatives told us, “the residents are as happy as they have ever been”. People requested support from the staff without hesitation and staff responded promptly and compassionately to requests. We saw people and staff were able to communicate effectively together and staff provided appropriate support and reassurance for people when they became upset or anxious.

People’s care plans had not been regularly updated to ensure they accurately reflected people’s current care and support needs. In addition the service used highly structured systems for recording details of the care people received each day. We found these records were missing significant pieces of information and did not adequately document that people’s identified needs had been met. We discussed these issues with the service’s new manager and the provider’s head of specialist care who agreed that the daily care records were not sufficiently detailed.

One person told us, “I go out quite a lot” while people’s relatives commented, “[people] seem to be kept very busy throughout the week.” People were encouraged and supported to engage with a wide variety of activities both within the service and the local community. On the day of our inspection many of the people who lived at Breage House were away for most of the day attending day centres and other activities they enjoyed. In addition we saw staff supported people to attend music concerts, sporting events and to go on holiday. One person told us two staff he recently supported them to go on a “fantastic” holiday to Disneyland, Florida.

The services quality assurance systems were effective. Prior to our inspection the provider’s head of specialist care had commissioned an additional staff survey and an external audit of the service as they had become concerned about the service’s effectiveness. This audit had identified many of the concerns identified in this report. Specific concerns had been prioritised and action plans developed to address and resolve the individual concerns. We found appropriate actions were being taken to address and resolve these concerns at the time of our inspection.

We found the service was well led. The provider had supplied significant additional management support to the service since the concerns about its performance had been identified. Staff told us; “In the last couple of weeks we have seen a lot more managers” and, “It’s nice to have the additional support at the moment.” The timely appointment of a new manager following the registered managers notice of resignation had ensured a smooth transition process.

We identified breaches of The Health and Social Care Act 2008 (Regulated Activity) Regulations 2014.  You can see what action we told the provider to take to address these breaches at the back of the full version of the report.

We observed and heard people interacted with each other and with staff in a way that was unrestricted and spontaneous. People were seen to be relaxed with each other. People we talked to were looking forward to the day, as a fete had been arranged to raise funds for the home. We heard two-way conversations between staff and people who lived at Breage House, which indicated acceptance and validation of people’s views.

We spoke with three care workers, the cook and the manager. The care workers and cook told us the home had changed for the better since the appointment of the manager. Staff told us training continued to be provided, they enjoyed working at Breage House, and they felt they could approach the manager and senior staff if they needed to.

Care records, and discussion with staff, confirmed people’s care needs were met, and that care reviews took place and was a dynamic process that responded to changing care needs. We saw people were offered the opportunity to make meaningful choices on a day to day basis.

The home adhered to a robust recruitment procedure that protected people, and staff were supported in their roles with the provision of regular recorded supervision.

Records were legible, up to date and stored securely, although not all required records were available for inspection.

We observed people interacted with each other and with staff in a way that was unrestricted and spontaneous. People were seen to be relaxed with each other. People we talked to were looking forward to the day, some going out with relatives, others to a pantomime. One person confirmed they would feel able to express any concerns if they had any. They told us they liked it at Breage House and said the staff were nice. Two relatives told us they thought the staff were good, but were concerned about the number of staff changes in recent months. Both said they especially had concerns about the changes in manager at the home. They told us they were not familiar with their relative’s care plan and also said communication could be better.

Staff told us training was provided, they enjoyed working at Breage House, and they felt they could approach the manager and senior staff if they needed to. Staff were confident they would feel able to report any perceived abuse.

We found people were treated with respect and their care needs were met. People were not always offered the opportunity to make meaningful choices. Staff were not supported in their roles with the provision of regular recorded supervision. Records did not reflect care needs or the care to be provided.