This inspection took place on 8, 9 and 30 October 2018 and was unannounced.

Brimstage Manor 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. Brimstage Manor is owned by Century Healthcare Limited.

The care home provides nursing care to people who have dementia and can accommodate up to 46 residents. During the inspection, there were 37 people living in the home.

At the last inspection in May 2017, we found that the provider was in breach of Regulation 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because person-centred care plans were not in place for all people and systems in place to monitor the quality and safety of the service were not effective. We asked the provider to complete an action plan to show what they would do to ensure the necessary improvements were made and we received this. During this inspection we looked to see if these actions had been addressed. We found that although some steps had been taken to address the concerns, further improvements were required to ensure the service was meeting required standards. We identified breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as well as Regulation 18 of Care Quality Commission (Registration) Regulations 2009.

There was no registered manager in post. A manager had been appointed and been in post since May 2018. They were in the process of applying to the Commission to become registered. However, following the inspection we have been informed that the manager is no longer working for 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 2008 and associated Regulations about how the service is run. The service is currently being supported by a manager from one of the providers other registered services, along with support from the operations director, until a new manager is appointed.

At the last inspection in May 2017, we found that not all people had care plans in place. During this inspection, we saw that improvements had been made and care plans were in place.

However, we found that care plans were mainly pre-populated printed plans with gaps for people’s names. We saw that these were not always completed fully. Care plans did not all contain accurate information to ensure that staff had clear guidance on how to best meet people’s needs and they had not all been updated regularly.

In May 2017, we found that the registered provider was in breach of Regulation as quality monitoring systems were not effective. During this inspection we looked to see if improvements had been made and found that systems in place to monitor the quality of the service were still not robust and had not identified the issues we highlighted during the inspection.

The provider had some systems in place to help ensure they remained aware of how the home was running. However, we found that the registered provider had not ensured that CQC were notified of events and incidents that occurred in the home.

Not all safe medicine administration practices were followed in the home. For example, people’s allergies were not always recorded. When people were prescribed medicines as and when required, they did not always have protocols in place to inform staff when to administer them. Advice from a pharmacist had not always been sought for people who required their medicines to be administered covertly (hidden in food or drink).

We found that although some risk assessments were in place, risks to people were not always fully assessed and mitigated.

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This inspection took place on the 31 May and 7 and 23 June 2017, the first day was unannounced. Brimstage Manor Nursing Care Home is a nursing care home for up to 46 people; at the time of our inspection 44 people were living at the home. The home is divided between an older Victorian style building called, ‘The House’ and a single storey modern wing called, ‘Hesketh’. The home had well-kept grounds and was in a countryside location. There was a newly appointed home manager who was in their first month of working at the home, they had not yet registered with the Care Quality Commission.

Staff and people’s relatives were positive about the new manager and their approach. Family members told us they were approachable and the manager had organised a family meeting for the week following our initial visit.

At the last inspection in April 2016, the service was rated overall Good. At this inspection we found the service was rated as Requires Improvement.

During this inspection we found that there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were of Regulation 9; Person-centred Care and Regulation 17; Good Governance.

We completed this inspection after concerns had been raised with us relating to the quality of care planning for people nearing the end of their life. We found that the end of life care planning in place was in the form of a ‘pre-palliative /holistic’ plan, which was generalised and did not offer staff enough guidance that was individualised to the person. At the point of being coded as amber on the end of life register this plan replaced more individualised and person centred care planning. We saw that some people had been on a ‘pre-palliative / holistic’ care plan for 19 and 22 months, without it being reviewed as appropriate after a period of time had elapsed.

At the time of our inspection the clinical director along with the newly appointed manager had already been reviewing the care files of each person. We saw some people’s care files where comprehensive care plans had been reinstated and updated for each aspect of a person’s care and the ‘pre-palliative / holistic’ generic care plan approach had stopped being used.

In other areas of care planning we saw that there was not sufficient information in people’s care files relating to pressure relieving mattresses and actions that had been taken to reduce the risk of falls. We also saw that in people’s care files there was a ‘getting to know you’ document containing information about a person, their background and preferences. A one page profile was kept in each person’s room which ensured that staff had to hand prompts and reminders to help them support people well. One family member we spoke with praised their relative’s recent experience of care planning at the home.

After our previous inspection we gave written feedback to the registered manager highlighting that at times care plans had not contained appropriate details to inform care staff. In these areas there had not been significant improvements. The systems that had been in place until recently had not been effective in gathering and assessing information about the quality of services provided to people and ensuring improvements were made.

Staff and visitors gave us mixed feedback about the number of staff available at the home and we saw one person waiting for care. We recommended that the manager review the numbers and deployment of staff members to ensure times of pressure on staffing levels are minimised.

People’s medication was administered safely. However improvements were required in the documenting of as and when required (PRN) medication and prescribed topical creams. We recommend that the manager review these procedures.

People told us they liked living at the home. One person said, “I’m very happy here, it’s quite good here.” During our visit there was a friendly and relaxed atmosphere at the home. We saw that the staff mad

This inspection took place on 26 and 29 April 2016 and was unannounced. Brimstage Manor is divided into an older main building called ‘The House’ and a modern wing called ‘Hesketh’. The home is registered for nursing care of up to 46 people. At the time of our inspection 44 people were living in the home. The Hesketh Wing was described to us as a single storey specialised dementia unit that had been added onto an original Victorian building. Brimstage Manor is set in well-kept grounds, containing a duck pond and paddocks in a countryside location.

There was a registered manager working at the home. 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 manager had a warm and kind approach to people and helped them with patience. We noted that she was familiar with people and knew them by name. During our visit we observed her taking time to stop and talk to people living at the home and their relatives. Staff we spoke with told us she was approachable and was visible at the home. People’s relatives also told us she was approachable and that communication from the manager and staff at the home was good. The manager had used questionnaires and conversations to gain feedback from family members about the care of their relative.

People’s care files we looked at were recent and they had the dates noted of regular reviews. They contained brief information about a person, their care plan and risk assessments. We found the information in people’s care documents wasn’t always up to date, complete, detailed enough or at times didn’t follow a logical pattern. We have made a recommendation that the manager review how care plans and other care documents are reviewed and updated at the home.

People living at the home and their relatives who we spoke with told us they felt the home was a safe place. There were security measures in place within the building. The home was clean. There were adequate staff available to support people. The staff were trained in and were aware of, safeguarding vulnerable adults. The home’s environment was safe and health and safety checks had taken place on the safety systems of the building, equipment used by people and the maintenance of the environment. Accidents and incidents were recorded and we observed some incidents had led to a quick response from the manager and staff when necessary. People’s medication was stored and administered safely by nursing staff.

People who lived at the home and their relatives told us they liked their rooms. People had been supported to put up their own pictures and ornaments in their rooms to personalise them. One in three of the rooms were ensuite. The Hesketh wing was described as an area of the home specialising in caring for people with dementia. However the corridors and dining room walls of the wing were all painted in one light mono-tone colour with no distinguishing features and they felt clinical. There were no dementia friendly signs or evidence of any adaptions or points of interest in the environment for people experiencing dementia. We have made a recommendation that the manager review current best practice on how the environments of a home can affect a person living with dementia.

We saw that staff were recruited and introduced to the home safely with the relevant checks in place. New staff received induction training when new to the role. All staff received training relevant to their role with longer standing staff receiving refresher training. We looked at the manager’s training plan which organised this. Staff told us and we looked at records that showed staff received regular supervision and annual appraisal. There was staff meetings held in which staff were update

During our visit we spoke individually with three people living at the home and with four of their visitors. We spoke to five members of staff who held different roles within the home and spent time observing the general care and support provided to people. We looked at care records relating to five people who lived at the home.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

At our last inspection of the home in May 2014 we identified concerns with the support people were given with their care and welfare. At this inspection we found the provider had taken action to address those concerns. We found that a review of the use of safety gates within the home had been carried out. As a result the use of these had lessened. Where they remained in use this was as a result of an assessment to ensure it was of benefit to the person.

At our last inspection of the home in May 2014 we found major concerns with the way the home safeguarded the people living there. At this inspection we found the provider had taken action to address those concerns. Training for staff in safeguarding adults was on-going and staff had an understanding of their role in identifying and reporting potential abuse. Information on how to report any safeguarding adults concerns had been displayed within the home so that visitors and staff could access it easily.

We saw evidence that potential abuse had been reported to the correct authorities for investigation under safeguarding adult's procedures.

Is the service effective?

At our last inspection of the home in May 2014 we found concerns with the support provided to people to make decisions or have them made on their behalf. At this inspection we found that some work had been undertaken to update assessments. However others lacked detail regarding the way in which the decision had been reached, the options considered and how it should be carried out. This could lead to decisions being made on the person’s behalf that may not be in their best interests.

Is the service caring?

People living at the home and their visitors told us that they were satisfied with the support they received with their care and welfare. A visitor described staff as, “lovely and kind” and we observed staff spending time interacting with people throughout the day as well as meeting their care needs.

Is the service responsive?

This was a responsive inspection to look at previous non-compliance against the regulations and we did not look specifically at this area. For information regarding this please refer to the report of our inspection carried out at the home in May 2014.

Is the service well-led?

A registered manager was in post at the home.

At our last inspection of the home in May 2014 we identified concerns with the systems in place to monitor the quality of the service provided by the home. At this inspection we found that action had been taken on the points raised at our last inspection. Audit files were readily available and audits had been undertaken in a number of key areas including, fire equipment, care plans and medication.

The inspection team who carried out this inspection consisted of two inspectors’. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

We used a number of different methods to help us understand the experiences of people using the service. This was because the people using the service had complex needs which meant they were not all able to tell us their experiences. Due to this we have used a formal way to observe people in this review to help us understand how their needs were supported. We call this the 'Short Observational Framework for Inspection’ (SOFI). We spoke with four people living at Brimstage Manor and met with several others. We also spoke with seven relatives and with nine members of staff who held different roles within the home.

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

At our last inspection of the home in November 2013 we found minor concerns with how the home safeguarded vulnerable adults. At this inspection we found major concerns. This was because incidents of abuse towards the people living at the home had not been reported to the relevant authorities for investigation and action as required. This meant that the home had not taken the appropriate action to safeguarding vulnerable people.

We found that some records relating to the running of the home could not be readily located by the person in charge of the shift. This meant that information they may need to carry out their role effectively was not available to them in a timely manner. We also found that the use of safety gates had not been risk assessed. It was therefore not possible to establish whether they were of benefit or a risk to people living at the home.

People had been cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly.

We observed that there were enough staff on duty to meet the needs of the people living at the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Assessments had been carried out and applications had been submitted to the appropriate authorities where they were identified as needed.

Is the service effective?

Overall assessments of people’s capacity to make decisions had been carried out. We found that these did not refer to a particular decision. An overall assessment stating that a person lacks capacity could lead to decisions being made on their behalf that are against their wishes and that they may have been able to make.

People living at the home and their relatives told us that they were happy with the care provided. Relatives told us that staff had been quick to note any health issues the person had and records we saw confirmed this. We observed that people had received support with their personal care and that staff knew people well and spent time interacting with them as well as meeting their care and welfare needs.

Staff told us that they had felt supported by senior staff and had received the training they needed. Training records showed that staff had undertaken a variety of training in relevant areas. However some of this training including supporting people with dementia and safeguarding adults’ had taken place some time ago.

Is the service caring?

The people living at the home and their relatives told us they had found staff kind and caring. One person told us, “The attitude is far more caring than I imagined.” Another person commented, “They have got time for you.”

During most of our inspection we observed staff spent time interacting with people and engaging them in activities However during the lunchtime meal staff had limited interaction with people.

Is the service responsive?

People’s needs had been assessed before they moved into the home. We found that care plans and risk assessments had been put into place to guide staff on how to support people with their care and welfare needs. These had been updated regularly and as people’s needs changed.

Is the service well-led?

A registered manager was in post at the home. Systems were in place for monitoring the quality of the service. These included seeking the opinions of relatives and professionals. However we found that decisions made in relation to safeguarding vulnerable adults were not in line with current guidance and legislation and may place vulnerable people at further risk. We also found that quality assurance audits failed to note a lack of detailed capacity assessments and a lack of assessments relating to the use of safety gates.

Due to the nature of the home it was inappropriate to engage with the service users due to their communication difficulties, we were only able to speak with one service user. As a result, we spoke with six relatives, four staff, observed care and reviewed four care plans. We saw and all relatives told us the home was always clean and free from odours. Relatives described the environment as “homely”.

The care plans we reviewed were all individualised and person centred. All care plans reviewed had a comprehensive social history. They were all well organised up to date. All had relevant risk assessments, such as:-falls, mobility, nutrition and bed rails which were reviewed monthly. Where appropriate the provider also had records of best interest assessments which were detailed, signed by the respective family and GP. All families we spoke to were aware of the care plans and most had been involved in there development. The care provider undertook audits of all care plans which we saw had been completed this year.

We saw the kitchen was clean and clutter free. We saw kitchen staff had food hygiene certificates. We spoke to the chef who told us how he catered for a variety of diets, for example, diabetic and vegetarian. Four out of the six relatives we spoke to all agreed the food was “very good” this was also supported by the one service user we spoke to.

The provider produced a training matrix which showed that most of the staff had training in challenging behaviour, dementia awareness and safeguarding. The provider might like to note that most of this was done in 2009 and needed updating.

Due to the nature of the home staff told us challenging behaviour was very common. The provider might like to note that it would be beneficial for all staff to attend a training update on how to manage challenging behaviour. When asked staff were able to tell us what they would do in such events but this was not necessarily the correct and safest way.

We spoke with four relatives and one person who used the service when we visited. People told us they were satisfied with the service provided at the home. They were treated well and with dignity and respect. They told us:

“It’s excellent”,

“Very nice home, the best she has been in”,

“It’s a lovely place, they are warm, caring and she is well looked after”.

People told us and we saw evidence that they were involved in care and treatment decisions, especially around end of life care. We observed that people were well cared for and treated with dignity and respect. People’s needs were assessed, planned and reviewed. We found that the provider monitored the quality of the service and gained views on the service from staff and people who used the service.

There were suitable numbers of experienced and qualified staff to look after people and their varying needs. They demonstrated an awareness and understanding of how to protect people from abuse.

We spoke to people who use the service, relatives and a catholic minister when we visited. Overall they told us they were very satisfied with the service provided at the home. People who use the service and their relatives told us they were involved in care and treatment choices and their preferences were taken into account.

We were told “They are very good”, “Wonderful – they respect my choices”, “The service is excellent. Communication is very good”.

We were told by relatives staff listened to their relative or themselves and took their views into account. They explained everything that was being done for their relative. People told us they were always respected and their dignity and privacy maintained especially when having personal care needs attended to. Relatives told us they were particularly pleased with the knowledge of the staff and felt they had a good understanding of individual needs. Those service users we spoke to expressed overall satisfaction with living at the home.