Brunel House is a ‘care home’ that provides a service for up to 65 people across three units which include nursing and dementia care. 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.

This inspection took place on 26 of September 2018 and was unannounced. We returned on 27 September to complete the inspection. At the time of the inspection there were 58 people living at the home.

At the last inspection dated July 2017 we found breaches of fundamental standards in relation to Regulations 5, 9,10 11 and 12. The provider developed an action plan detailing how they would take steps to meet the requirements of the legislation and action plans were monitored by the provider. While we found that some improvements had been made these were insufficient in all areas.

This is the second consecutive time the service has been rated Requires Improvement

A registered manager was 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.

There was a programme of monthly audits included sample checks of care plans and medicine audits. We saw there were repeated issues in relation to medicines. Clinical audits were monthly and related to areas of risk such as pressure areas, weight and falls. Along with reports of commissioners visits we raised with the registered manager that reports of daily entries were not person centred. For example, staff documented reports of clinical support and direct care provided. The registered manager explained how this was to be addressed. However, records were not always up to date and accurate.

Risk management systems were used to assess people’s individual level of risk. Action plans were devised where risks were identified. However, risk assessments were not always updated to show where the risk had increased and monitoring checks were not consistently completed.

Care plans were not always person centred. Some care plans were inconsistent with the aim of the plan, the individual’s abilities and current needs. Some end of life care plans although included the priorities of care lacked person centred care. Daily notes were task focused and included direct care delivered. Where people used repetitive behaviours care plans were not always in place on how staff were to manage these behaviours.

There was an electronic system for medicine administration and audits of medicine systems showed there were persistent issues. The audit reports showed that staff were not signing when cream and lotions were applied. In the dementia unit we noted a number of people were prescribed with medicines for anxiety. The protocols were not person centred and did not give clear guidance on how people expressed anxiety.

The home was clean well decorated and free from unpleasant smells. We saw housekeeping staff on duty within the home.

The staff we spoke with knew the types of abuse and to report their concerns. They said they had attended safeguarding adults training to help them recognise the signs of abuse and about reporting concerns. People said they mostly felt safe living at the home. The registered manager told us the actions they will take to ensure people felt safe from those that made them feel at risk of harm.

We saw adequate number of staff available to support people with daily needs. People told us the staff responded to their request for support and assistance. They said if staff had time they took the time to have a chat. Relatives said occasionally staffing levels dropped especially at weekends. Some staff told us they felt rushed and expressed th

At the last inspection dated 30 June 2015 we found breaches of fundamental standards in relation to person centred care and for consent to care. The provider developed an action plan detailing how they would take steps to meet the requirements of the legislation. While we found that some improvements had been made these were insufficient in all areas and we have repeated these breaches.

This inspection was over two days which took place on 19 April and 2 May 2017. The visit on the 19 April was unannounced and the manager was aware of the second visit on 2 May 2017.

Brunel House provides a service for up to 65 people. The staff provide care and treatment to people with nursing needs and to people living with dementia.

A registered manager was not in post. The current manager will be making an application to register with us. 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.

Risks were not managed appropriately. Risks assessments on how staff were to minimise risk were not always in place and staff had not recognised when people were at risk of harm. For example, risk assessments were not in place for people at risk of choking. Where risk assessments were in place they lacked detail on how staff were to minimise the risk. For example, how staff were to support people when they became anxious.

Waterlow assessments were completed by the staff to identify the potential of people developing pressure ulcers. Action plans were not developed on how to minimise the potential of skin breakdown. Body maps were used to locate the position of injures but reviews had not taken place to monitor the healing progress of the wounds.

Incidents and accidents were not always reported by the staff. We saw where people had sustained injuries managers were unaware of them having occurred. This meant accidents and incidents were not fully analysed to prevent any reoccurrence. The manager said where accidents and incidents were reported the quality assurance team shared learning from an analysis of trends and patterns.

Medicine systems needed improving. Protocols for when required medicines (PRN) were not in place for all PRN medicines and where they were in place they lacked detail. Protocols lacked detail on the signs which identified to staff that PRN medicines were needed. Care plans were not in place for the administration of covert (disguised) medicines. Guidance on the best method of disguising the medicine was not sought from the pharmacist.

Staff’s opinion on the quality of training was mixed. Some staff said the online training provided did not provide an opportunity for the staff team to share learning. Other staff said the quality of the training was poor for example, Mental Capacity Act 2005 (MCA) training and other staff said higher level of dementia training was needed for staff working on units where people were experiencing dementia .

The staff were knowledgeable about how to enable people to make day to day decisions such as menu choices, activities and what people would like to wear. We saw good examples of staff supporting people to make choices. However, staff lacked knowledge of the MCA and were not working within the principles of the act. Guidance from healthcare professionals was consistently disregarded for one person. MCA assessments were not undertaken to ensure where people had cognitive impairments they had the ability to understand the consequences of the decision taken.

People were not involved in the planning of their care. Care plans were inconsistent and lacked detail on how staff were to deliver care and treatment in people’s preferred manner. Care plans on how staff were to manage difficult behaviours when people living w

The manager assisted us with the inspection and gave us a tour of the home. We saw people moving around the communal areas of the home and we had a midday meal with some people. When we spoke with people they told us they were happy with the support they received and that staff treated them with respect. It was evident through observation and discussions with staff that they enjoyed working in the home and supporting people.

Appropriate checks were undertaken before staff began work. Recruitment was underway for nurses, a deputy manager and domestic staff. Staff had received training in key areas so that people were supported safely and protected from harm.

Senior managers visited the home regularly to monitor all aspects of the running of the home including the care people received, the records held, and staffing.

People and their family members were asked for their views about the quality of the service. We spoke with two relatives, and three staff. Comments made by relatives included “a few staff go the extra mile” and gave examples of when some staff had supported their relative in a caring and kindly way. Other comments relating to people’s care included “very well looked after, they do well” and “like a hotel, can’t fault it at all”.

Brunel House provides a service for up to 65 people. The staff provide care and treatment to people with nursing needs and to people living with dementia.

The inspection of Brunel House was unannounced and took place on the 30 June and 1 July 2015.

A registered manager was in post and was registered by the Care Quality Commission (CQC) in 2014. A registered manager is a person who has registered with the CQC to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People were not aware they had a care plan. Care plans did not give detailed guidance to staff on how they were to meet people’s needs. People’s preferences were not included in their care plan which meant care plans were not personalised.

Some risks were assessed and action was taken to mitigate risk. Incidents and accidents were analysed to identify trends and patterns. However, some injuries had not formed part of this analysis. Risk assessments were not developed following a number of injuries sustained by the same object until we drew this to the attention of the registered manager and area manager.

People and some staff said the staffing levels did not meet people's needs. They said staff had left and more staff were not recruited to the vacant hours. Some people said the deployment of staff when staffing levels were poor in other units had caused them anxiety. The area manager told us from their assessment they were satisfied suitable staffing levels in place were suitable.

New staff received an induction when they started work at the home. Staff attended training which helped them to develop the skills needed to meet people’s needs. Staff made suggestions about the delivery of training. They said to allow for more scenario discussion face to face or in-house training would be more beneficial.

People’s capacity to make decisions was assessed. However, staff had not fully completed the forms used to record assessments of capacity. Staff were not always using the provisions of the MCA to make best interest decisions such as consent for bed rails, photographs.

People said the meals served were good and the menu was varied but the quality of the food needed improving. We saw there was a good range of fresh, frozen and dried produce. However, we saw a large quantity of basic/value produce. This may mean food products were of low nutritional value.

Management systems in place ensured there was a supporting culture. Staff said the registered manager was approachable but the staff in head office did not take their concerns seriously and this negatively impacted on staff morale. Quality assurance arrangements were effective and ensured people's safety and wellbeing.

People said the staff were caring, their rights were respected and their views about the service were sought. Staff had a good understanding of developing positive relationships with people which created an environment where people felt respected.

People knew who to approach with their complaints and they felt confident their concerns would be taken seriously.

People were protected from physical, psychological and emotional harm. Staff attended safeguarding adults training which ensured they knew the types of abuse and the procedure for reporting allegations of abuse.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 . You can see what action we told the provider to take at the back of the full version of the report.