Archived: Braemar Care Centre

Updated 27 July 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 15 and 23 June 2017 and was unannounced. There were three adult social care inspectors on the first day and two inspectors on the second day.

We reviewed information we held about the service, such as notifications, information from the local authority and the contracting team. We displayed a poster to inform people and visitors that we were inspecting the service and inviting them to share their views. We had received a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We looked around the home, in people’s rooms with their permission and in communal areas. We spoke with eight people, the manager, three care staff, the activity co-ordinator, the acting cleaner, the maintenance staff, the cook and two visiting doctors. We spoke with three visiting relatives.

We looked at care documentation for five people, two recruitment files and records relating to quality assurance monitoring and the safety of the premises and equipment.

Updated 27 July 2017

The inspection took place on 15 and 23 June 2017 and was unannounced. The previous inspection was 15 December 2016; the ratings following the last two inspections have been inadequate and we are taking enforcement action in relation to the findings. The service was in special measures at the time of this inspection. This inspection identified some improvements, but also continued breaches in regulations 12 safe care and treatment and 17 good governance. We also identified a further breach in regulation 18, staffing.

Victoria Lodge Residential Home provides accommodation for up to 24 older people who require personal care. It also cares for people who have a diagnosis of dementia. At the time of the inspection there were eight people using the service. The home is situated in Edenthorpe, near Doncaster.

There was a manager in post who had applied to register with the Care Quality Commission and this application was in progress at the time of the inspection. 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 and associated Regulations about how the service is run.

The environment was homely and welcoming. People were content in the home and staff were attentive to their needs. People had good relationships with staff who were knowledgeable about their individual needs and personal preferences. Staff promoted people’s dignity well in all interactions and were respectful when speaking with or about people.

Individual risks to people were not fully assessed and information in people’s care plans did not sufficiently illustrate how care should be managed safely.

Staff felt supported by the manager and there was evidence of training and supervision, however training was not all up to date or effective. There were only three qualified first aid trained staff altogether and this meant they were not always on duty.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff sought people’s consent for all aspects of care and support.

People enjoyed their meals and staff had an understanding of people’s nutritional needs, although risks around people's nutrition were not effectively monitored. There were snacks and drinks available throughout the day.

Activities were person-centred and meaningful to individuals and staff had a good insight into people’s backgrounds, interests and hobbies.

Care plans showed where people’s care had been discussed with other professionals and reviewed. However, documentation to support people’s care and the running of the home was not all up to date, clear or concise, which meant information was fragmented and not easy to locate.

There were continued weaknesses in the systems and processes for assuring the quality of the service and issues identified through the inspection process were not routinely picked up on within the audits.

We noted the manager and the staff team were working hard to address the concerns raised at the last inspection and they had made positive changes, particularly in relation to people’s dignity and activity provision. The manager was very responsive to matters raised at this inspection and took measures to address the issues we raised. However, there were continuing concerns at this inspection in relation to the oversight and management of risk, documentation to support people’s care and the running of the home and governance.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that although some improvements had been made, there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

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