This was an unannounced inspection which we carried out on 31 January 2017.

We last inspected Brunswick House in September 2015. At that inspection we found the service was not meeting all its legal requirements with regard to staffing levels. At this inspection we found that action had been taken to meet the relevant legal requirements.

Brunswick House provides personal and nursing care to a maximum of 41 older people, including people who live with dementia or dementia related conditions. At the time of inspection 37 people were living 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.

At our last inspection we found staffing levels on the middle floor were not sufficient to meet people's needs. At this inspection we found the breach had been actioned with regard to staffing levels on the middle floor of the home. However, we have made a recommendation that the service undertake a full review of the dependency levels of people to check how many staff are needed to effectively meet people’s needs, and adjust staffing levels accordingly to ensure the needs of people across the home are met in a timely way.

Risk assessments were in place and they accurately identified current risks to the person as well as ways for staff to minimise or appropriately manage those risks. People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse.

Staff received opportunities for training to meet peoples' care needs and in a safe way. A system was in place for staff to receive supervision and appraisal and there were robust recruitment processes being used when staff were employed. Staff had a good understanding of the Mental Capacity Act 2005 and best interest decision making, when people were unable to make decisions themselves. People were able to make choices where they were able about aspects of their daily lives.

Staff were patient and kind as they supported people. People and their relatives spoke highly about the care they or their relatives received.

People had access to health care professionals to make sure they received appropriate care and treatment. Staff followed advice given by professionals to make sure people received the care they needed. People received their medicines in a safe and timely way.

A complaints procedure was available. People told us they felt confident to speak to staff about any concerns if they needed to. Staff and people who used the service said the registered manager was supportive and approachable. People had the opportunity to give their views about the service. Feedback was acted upon in order to ensure improvements were made to the service when required. The provider undertook a range of audits to check on the quality of care provided.

Records were regularly reviewed to reflect peoples' care and support requirements. Staff supported people who required help to eat and drink and special diets were catered for. Activities and entertainment were available for people and people were consulted to increase the variety of activities and outings.

This was an unannounced inspection carried out on 24 September 2015.

We last inspected Brunswick House in October 2014. At that inspection we found the service was meeting all legal requirements in force at the time.

Brunswick House is a 40 bed care home that provides personal and nursing care to older people, including people who live with dementia or a dementia related condition.

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.

People said they were safe and staff were kind and approachable. We had concerns however there were not enough staff on duty to provide safe and individual care to people.

People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse. When new staff were appointed, thorough vetting checks were carried out to make sure they were suitable to work with people who needed care and support. Appropriate training was provided and staff were supervised and supported.

Systems were in place for people to receive their medicines in a safe way. However, we have made a recommendation about the management of medicines.

People had access to health care professionals to make sure they received appropriate care and treatment.

Brunswick House was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Best interest decisions were made appropriately on behalf of people, when they were unable to give consent to their care and treatment.

People received a varied and balanced diet to meet their nutritional needs. However people who lived with dementia were not all encouraged to make choices with regard to their food.

Staff knew the people they were supporting well. Care was provided with kindness and most people’s privacy and dignity were respected.

There were limited activities and entertainment available for people.

A complaints procedure was available. People told us they would feel confident to speak to staff about any concerns if they needed to. The provider undertook a range of audits to check on the quality of care provided.

People had the opportunity to give their views about the service. There was regular consultation with people and/ or family members and their views were used to improve the service. People had access to an advocate if required. Advocates can represent the views of people who are not able to express their wishes.

Staff and relatives said the management team were approachable. Communication was effective to ensure staff and relatives were kept up to date about any changes in people’s care and support needs and the running of the service.

You can see what action we told the provider to take at the back of the full version of the report.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

The reason for this visit was to check if improvements had been made in areas of care and welfare and to see if staffing levels had increased.

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

-Is the service safe?

-Is the service caring?

-Is the service well-led?

-Is the service responsive?

-Is the service effective?

This is the summary of what we found.

Is the service safe?

We saw there were arrangements in place to ensure there were enough staff on duty to ensure people's needs were met in a safe and timely way. Records showed staff had enough information to provide individual care and support to people in a way that the person wanted.

Is the service caring?

This was a responsive inspection to previous non-compliance against the regulations and we did not look specifically at this area.

Is the service responsive?

We saw there was a variety of activities that were available and we were told they were being arranged according to individual interests. One person said; "A group of us sometimes play Monopoly." Some people told us they enjoyed the seasonal parties and entertainment that was available. People told us they were supported by staff to go out. One person told us they went out to church with staff. Another person said; "I'm looking forward to going out for the Christmas meal." Another said; "I sit in the garden even in the winter." We were told a person who was 100 had attended a meal at Alnwick Castle with other centenarians to mark the centenary of the First World War.

Is the service effective?

We saw staff with the appropriate skills and qualifications were available to ensure people's health and social care needs were met.

Is the service well-led?

We were told a new manager had been appointed since the last inspection. We were told the manager would be making an application for registration with the Commission as the manager of this location, in line with the requirements of the registration of the service. We saw the action that had been taken and the plans for improving quality outcomes for people who use the service. For example with regard to activities and outings, staffing and ensuring the environment was becoming more suitable to help maintain the independence of people who lived with dementia.

In this report the name of registered managers appear who were not in post and not managing the regulatory activities at this location at the time of the inspection. Their names appear because they were still a Registered Manager on our register at the time.

We were informed an existing member of staff had just been promoted to become the new manager.

This inspection began out of hours at 5:45 am in the morning.

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

.Is the service safe?

.Is the service effective?

.Is the service caring?

.Is the service responsive?

.Is the service well-led?

This is the summary of what we found.

Is the service safe?

An assessment of people's care and support needs was carried out before people started to use the service. This was to ensure staff had the skills and had received the training in order to safely meet the person's support requirements.

Risk assessments were in place. People were supported and encouraged to maintain their independence and this was balanced with the risk to the person. Audits were carried out to look at accidents and incidents and the necessary action was taken to keep people safe.

Information was available to show that the service worked with other agencies to help ensure people's health needs were met and to prevent admissions to hospital wherever possible.

We saw there were not enough staff on duty at the time of inspection to ensure the care and supports needs of people were met in a safe and timely way.

Is the service effective?

We saw the environment was not suitably designed to meet these needs and there was little evidence of the involvement of people with dementia in daily decision making about their care needs.

People commented how helpful and friendly the workers were. Relatives told us the service kept them up to date with what was happening with their relative's care and they felt able to ask any questions. Two people who lived at the home commented; "I like living here." And "Staff are kind."

We saw record keeping was not effective as written information was not available in all areas of care to reflect the care and support provided by staff.

Staff were observed to be patient and supportive as they worked with people.

Is the service caring?

Most people and relatives spoken with talked well of the level of care provided by staff. We found people with dementia or cognitive impairment were not sufficiently involved in daily decision making. Staff were helpful and offered people information and support about their care. We saw most staff interacted well with people and it was evident that staff had developed a good understanding of people’s communication needs and how best to communicate with them. However due to the low staffing level, on the top floor, staff had little, or no time to spend interacting and engaging with people.

Is the service responsive?

Information was collected by the service with regard to the person's ability and level of independence before they moved into the service. Various assessments were completed by the manager of the service with the person and/or their family to help make sure staff could meet their needs. Regular reviews were carried out with the person who used the service and their representative to make sure plan's of care were kept up to date. This helped ensure staff provided the appropriate amount of care and support.

Referrals for specialist advice were made when staff needed guidance to ensure the health needs of people were met.

People's individual needs were taken into account and they, or their representative if they were not able, were involved in decision making with regard to their care. They were kept informed and given some information to help them understand the care and choices available to them, however this was not developed sufficiently to involve people with dementia.

Information collected by the service gave staff some insight into the interests and areas of importance to the person. Activity provision was not sufficiently developed to help ensure activities reflected people's interests and provided stimulation to people with dementia. Activity provision and opportunities for socialisation were not offered by support workers when activities personnel were not on duty. Staff we spoke with and people who used the service said there was little time for any socialisation and engagement as staff were kept so busy with other tasks.

Regular meetings took place with staff and people who used the service and their relatives to discuss the running of the service and to ensure the service was responsive in meeting the changing needs of people.

Is the service well-led?

There was a focus from management on the provision of individual care and support to people who used the service. However there was less emphasis about individualised care and support to people with dementia and cognitive impairment. Staff were knowledgeable about the support needs of people.

We saw people had the opportunity to comment on the quality of the service and that they felt able to speak to the manager and staff about any issues.

People were given all the information they needed to make an informed decision about their care and were asked to provide their consent to such care.

We saw people were cared for effectively and care was planned for the individual.

We saw people were safe and protected from abuse.

We saw there was sufficient staff to provide care and support.

The provider had an effective system in place to monitor their quality assurance and record and monitor complaints. Complaints were taken seriously and responded to appropriately.

The representatives or advocates of people who used the service were positive about the care and support provided. Comments included “The care is very good here” and “I am involved in decisions about my care and the staff are very good”.

We spoke with sixteen people living in the home and spent time on each of the three floors.

Those able to express an opinion told us they were happy and were well cared for. They all confirmed that they got up when they wanted to and that staff consulted with them before helping them with their personal care.

One person, who was new to the home, said he was well looked after and that he was, “very contented indeed”. He also said, “Everything’s been perfect. I’m happy with everything here”.

Other comments included, “It’s a pleasant place to live. The food’s good and there’s plenty of choice”; “We are treated with respect here”; “I’m comfortable and I know nothing dreadful will happen to me here”.

In relation to the staff, comments included, “The staff are very good – they know what to do”; “They know what I like and how much I can do”; and, “They are always patient and careful when helping me”.

We spoke with people using the service, but due to their needs, some people could not offer direct comments about the care they received.

We did not speak with people living in the home about their medicines. We saw that medicines were given at the appropriate times and we heard care workers talking to people kindly and patiently when medicines were given.

Due to their needs, some people could not offer direct comments about the care they received. We spent some time observing the care offered to people and also spoke with a visiting relative.

People appeared generally relaxed, and there was a warm atmosphere between those living here and staff.

We did not speak with people who use the service

On the day of the visit we were unable to speak to anyone using the service about their medicines.

Although some concerns were identified, the majority of people using the service were

satisfied with the quality of care and treatment they received.