Little Brook House offers accommodation for up to 20 people who require personal care, including those who are living with dementia.

The inspection was unannounced and was carried out on 13 and 19 January 2017.

At our previous inspection in July 2015 we identified the provider was not meeting a number of regulations. These related to safeguarding people from abuse; risk assessment; person centred care; staffing levels; staff training and supervision and recruitment; safe management of medicines; and good governance, including record keeping and monitoring and assessing the quality of care and health and safety and the environment. We issued enforcement notices in relation to person centred care; safeguarding adults from abuse; good governance and staffing levels. Following the inspection, the provider sent us an action plan telling us the steps they were taking to make the improvements required.

We inspected again in January 2016 to check they had met the requirements of the enforcement notices and found they had made the required improvements. However, we identified some on-going issues with regards to the provision of person centred care and staff training and supervision. We judged that the provider remained in breach of these two regulations.

At this inspection we found significant improvements had been made.

There was a registered manager in place at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

The registered manager had identified and implemented a number of service audits and monitoring systems. Whilst improvements had been made as a result of these, there was still some work to do to fully embed these new systems for monitoring and assessing the quality and safety within the home. Incidents and accidents were recorded and actions taken, although there were some missed opportunities to learn lessons from these.

People and relatives told us they felt the home was safe. Staff had received safeguarding training, demonstrated an understanding of key types of abuse and explained the action they would take if they identified any concerns.

Individual and environmental risks relating to people’s health and welfare had been identified and assessed to reduce those risks.

Systems were in place for the storage and administration of medicines, including controlled drugs. Staff were trained and their competency assessed to administer medicines.

Staff followed legislation designed to protect people’s rights and ensure decisions were made in their best interests. The registered manager understood Deprivation of Liberty Safeguards and had submitted requests for authorisation when required.

There were sufficient staff deployed to meet people’s care, emotional and social support needs. Activities staff were employed to engage people in planned activities throughout each week.

Staff treated people with dignity and respect and ensured their privacy was maintained. Staff were kind and caring, had time for people and sat and listened to them when they wanted to talk.

People were supported to maintain their health and well-being and had access to healthcare services when they needed them.

Initial assessments were carried out before people moved into Little Brook House to ensure their needs could be met. Information was used to develop plans of care for people. A new electronic care planning system was in the process of being implemented.

The service was responsive to people’s needs and staff listened to what people said. People and, when appropriate, their families or other representatives were involved in decisions about their care planning.

People were supported by staff who had received an induction into the home and approp

Little Brook House is a privately run residential home for up to 25 older people, some of whom are living with dementia. The home also provides a respite service. There were 18 people living at the home at the time of our inspection.

The home had a new registered manager. 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.

At our unannounced inspection on 26 June 2014, the provider was in breach of six regulations relating to; Respecting and involving people who used the service; Care and welfare; Safeguarding people from abuse; Safety and suitability of premises; Staffing; and Assessing and monitoring the quality of the service. The provider sent us an action plan telling us what they would do to meet the requirements.

We carried out a further unannounced comprehensive inspection on 30 & 31 July and 3 & 19 August 2015 under the new Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and found some improvements had been made. However, the provider remained in breach of six regulations relating to; Care and welfare of people; Safeguarding people from abuse; Safe care and treatment; Staffing; Fit and proper persons employed; and Good governance.

We took action and issued enforcement notices against the provider in relation to Care and welfare of people; Safeguarding adults from abuse; Staffing and Good Governance due to the on-going breach of these regulations. We told the provider they must meet the requirements of these regulations by 14 December 2015. The provider sent us an action plan to tell how they would do this and to tell us how they would make improvements to meet the other regulations.

We undertook an unannounced focused inspection on 21 January 2016 to check they had followed their plan and to confirm that they now met legal requirements in relation to the enforcement notices. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Little Brook House on our website at www.cqc.org.uk. We did not inspect the other breaches of regulation at this inspection and will do so when we return to carry out our next comprehensive inspection.

Staff had received training in how to safeguard adults from abuse. They understood how to recognise the signs of abuse and report any concerns within the home or to CQC. We judged that the provider had fully the met the requirements of this enforcement notice.

There were sufficient staff deployed to meet people’s care needs. We observed staff responding promptly to people’s requests for support. Staff told us there were enough staff most of the time, although there were still times when they were stretched. People told us there were enough staff to meet people’s personal care and support needs although some people we spoke with said staff did not have time to sit and chat with them. The registered manager told us they were recruiting additional staff and would be increasing staffing on each shift.

Staff had completed additional training in some key areas. However, there were outstanding training requirements for several staff. The registered manager had a training schedule in place for the next twelve months, although we told them that this needed to be completed more urgently due to the length of time training had been outstanding. We judged the provider had met the requirements of the enforcement notice. However, there was still further work to be done.

Care plans and other records had improved. The registered manager was in the process of transferring care plans over to a new format and this was a work in progress. However, some people’s care plans

We brought forward our planned inspection of Little Brook House (the home) because we had received information of concern that alleged the welfare people living there had been compromised.

At the time of our visit 20 people were accommodated at the home. We spoke with eight people who lived at the home during our inspection in order to hear about their experiences of living at the home.

We spoke with three care staff and the home’s manager in order to hear what they had to say about how the home functioned.

We contacted two local GP surgeries to obtain their opinions about the care their patients received at the home.

We gathered evidence against the outcomes we inspected to help answer our five key 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.

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

Is the service caring?

People told us the home’s staff were polite, helpful, willing and cheerful. They said their choices and preferences were respected and told us they were involved in decisions about the care and support they received.

People’s privacy and dignity was not always respected.

Is the service responsive?

A local General Practitioner (GP) with patients who lived at the home, told us they thought the following about Little Brook House. “The home is well run with caring staff. Carers are generally helpful and well informed. Management of patients is satisfactory. Requests for visits are appropriate. Patients like the ambience of the home and the catering is exceptional”.

Nationally recognised assessment tools were not used to identify the potential risk of harm to people from matters such as pressure sores, falls and malnourishment.

People’s needs had not always been comprehensively assessed or the support they required planned in a way that reflected relevant guidance and ensured their safety and welfare.

Is the service safe?

People could be sure they were cared for, or supported by, suitably qualified, skilled and experienced staff.

People who used the service, staff and visitors were not properly or fully protected against the risks of unsafe or unsuitable premises.

The registered person had not responded appropriately to allegations of abuse.

Our review of records showed people were not protected from the risks of unsafe or inappropriate care and treatment because their records did contain all the proper information about the support they needed.

Is the service effective?

Care and treatment was not planned and delivered in a way that was intended to ensure people’s safety and welfare and avoid unlawful discrimination.

Is the service well led?

The provider had arrangements in place to check and monitor the quality of the service people received however systems to manage risks to the health, safety and welfare of people using the service were not sufficiently robust.

We spoke with three people who use the service, one relative, two staff and the registered manager. We looked at care and management records for the service and observed care given during our visit.

One person told us "I couldn't have come to a better place, I am very happy here." Another person said "The food is great and the garden is truly beautiful." A relative told us "I feel assured that mum is receiving the best care available. Nothing is too much trouble for the staff."

We found people were involved in writing and reviewing their care plans and had signed them when they were amended. Their needs were assessed and these needs were identified in the care plans. Staff told us they followed the care plans and we saw this where a person was given their medication.

Medicines were administered safely and when people required them. Appropriate systems were in place to order and store medicines. The staff maintained appropriate records of administration.

We looked at staffing and found staff were suitably skilled and qualified for the roles they carried out. There were sufficient numbers of staff on duty and the manager told us they worked on the floor when extra support was required.

We found the service had an effective complaints system in place and complaints were listened to in good time. The service responded to complaints and worked with the complainant to reach a favourable solution to them.

We spoke with a group of ten people living in the home and were told that they were very happy with the care that they received from staff. They felt they were treated with dignity and respect and that their privacy was maintained at all times.

They told us that they had regular residents meetings and their views were listened to and they could raise any concerns they had.

People told us they liked living at Little Brook House. They told us they felt they were involved in the running of the home and were consulted over decisions made in the home. People told us they knew and liked the staff, who treated them with respect and dignity. They told us they had confidence in the manager and felt they would be able to solve any problems they may have.

Little Brook House is a privately run residential home for up to 25 older people, some of whom are living with dementia. The home also provides a respite service.

The home had a registered manager. 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.

At our previous inspection on 26 June 2014, the provider was in breach of six regulations relating to; Respecting and involving people who used the service; Care and welfare; Safeguarding people from abuse; Safety and suitability of premises; Staffing; and Assessing and monitoring the quality of the service.

The provider sent us an action plan telling us what they would do to meet the requirements. At this inspection the provider had made some improvements but we found some on-going concerns.

Staff understood how to recognise the signs of abuse and knew how to report their concerns, if they had any, within the home or to CQC. However, not all staff had received safeguarding training and were not all able to identify the Local Authority safeguarding team which is the lead safeguarding agency.

Staffing was not sufficient and had not been increased following the opening of a five bedded extension in January 2015 and an increase in people living at the home. Staff told us there were not enough staff and said they did not have time to sit and chat with people or provide one to one time. The manager and team leader had not completed on going management tasks because they were required to help provide support to people. People told us they were often bored and there were not enough staff on duty. The home had employed a part time activity co-ordinator, but we did not see any activities taking place during the inspection.

There was a positive and caring atmosphere in the home. Staff interacted with people with kindness and respect and promoted their independence. Staff felt respected and listened to by the manager. They felt supported by the manager and team leader. However, training was not sufficiently robust to ensure all staff were competent to carry out their role.

The provider could not be assured their recruitment practice was safe because recruitment documentation for staff was inconsistent or missing. There were no photographs, identification documents or health assessments in some staff records.

Care plans and other records were not always sufficiently comprehensive to provide staff with the information they needed. However, despite this people whose care we tracked had received appropriate healthcare interventions when required. Staff were aware of people’s individual risk assessments and knew how to mitigate the risks, although this was not always recorded effectively.

Medication was stored safely and administered by staff who had been trained to do so. There were procedures in place to ensure the safe handling and administration of medication. However, medicines were not always ordered in a timely way and there were some gaps in recording and follow up of administration of medicines, particularly the application of creams.

Systems were in place to assess and monitor the quality of the service although these were not always effective. Most of the provider’s policies were out of date or had been reviewed but not effectively. For example, they had not been amended to reflect changes in legislation.

People were asked for their consent before care or support was provided and where people did not have the capacity to consent, the manager acted in accordance with the Mental Capacity Act 2005. People’s mental capacity was assessed when specific decisions needed to be made, and were made in their best interest involving relevant people. Deprivation of Liberty Safeguards (DoLS) applications to the local authority had been submitted where appropriate. However, not all staff understood best interest decisions or whether people had a DoLS in place.

Maintenance and servicing of equipment and the environment was managed effectively.

At our previous inspection we found six breaches of regulations. At this inspection we identified six breaches of regulations. You can see what action we have told the provider to take at the back of the full version of the report.