Brownlow House

Brownlow House is a residential care home registered to provide accommodation with personal care for up to 31 people. The service provides support to adults with dementia, mental health needs or with a history of alcohol and substance misuse. At the time of our inspection there were 28 people using the service. Brownlow House accommodates people in one adapted building.

People’s experience of using this service and what we found

We have recommended the service reviews their medicines audits . Regular health and safety checks were conducted at the service. Staff wore personal protective equipment (PPE) appropriately throughout the inspection and the home appeared clean. Staffing levels were reviewed on a monthly basis in line with people’s needs. Staff were recruited safely.

Staff received appropriate training during their induction and ongoing development. Staff supervisions took place regularly. Staff supported people to eat and drink and access healthcare services.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff knew people well and supported them in a dignified way. People were supported to express their views and be involved in their care planning. People told us that staff supported them with good humour.

Care plans were personalised. People were supported to take part in activities they enjoyed either as a group activity or for walks on their own. End of life care plans clearly outlined the support people would like at that time.

Staff and people living at the service felt they could approach the registered manager. There was an improvement plan in place at the service. Audits were being completed at the service. Since the last inspection the service were using a new system for care planning and to record accidents and incidents.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 September 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider reviews good practice guidance in relation to the management of medicines. At this this inspection we found the provider had made some improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Brownlow House is a residential care home registered to provide accommodation and support with personal care for up to 31 people. The home was providing support to both younger and older adults who were living with dementia, had mental health support needs and a history of substance or alcohol misuse.

Accommodation is provided over three floors and there is a passenger lift between floors. There were a number of communal lounges and dining areas and an accessible garden. At the time of our inspection there were 29 people living at the home.

People’s experience of using this service and what we found

Staff had received a range of relevant training and felt confident they were able to meet the needs of people living at the home. However, few staff had received relevant training in relation to mental health or substance/alcohol misuse.

There was a consistent staff team and staff knew people living at the home well. We received positive feedback from people about the caring approach of staff. However, during the inspection we observed some poor interactions that lacked respect towards people living at the home. We discussed these concerns with the registered manager.

Staff assessed risks to people’s safety and wellbeing and in most cases, followed recorded plans to help keep people safe. However, improvements were needed to how the provider managed the health and safety of the premises, and how they managed medicines safely.

People felt that staff understood and met their needs and preferences. Care plans were person-centred. Staff supported people to access the local community, but there were few organised activities and some people felt bored and that there was a lack of stimulation.

Staff told us they enjoyed their jobs and felt supported by the registered manager. Since our last inspection, the registered manager had started to be based full-time at Brownlow House, which gave them increased oversight of the service. However, further improvements were needed to strengthen systems in place for monitoring and improving the quality and safety of the service and ensuring all regulatory requirements were understood and met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We have made two recommendations. These relate to reviewing and implementing current guidance about meeting people's needs in relation to activities and occupation and managing medicines.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (report published 19 December 2018). This is the fourth consecutive time the service has been rated requires improvement over the past three years.

At our last inspection we found multiple breaches of the regulations and served a warning notice for one regulation. We met with the provider and registered manager to discuss how they would improve the service. At this inspection we found enough improvements had been made for us to judge the service to be meeting the requirements of the regulations. However, further improvements were needed.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to managing the safety of the premises and good governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor the service and will request an action plan detailing how they plan to make improvements to ensure the service’s rating improves to at least good overall. We will return to inspect the service as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Brownlow House 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.

Brownlow House is registered to provide accommodation, support and personal care for up to 31 people. The home provides support for people living with dementia, have a mental health issue and people who have had a history of abusing alcohol.

At the time of our inspection 29 people were living at Brownlow House. Brownlow House is an older building with three floors, accessed by a lift. People used shared bathrooms on each floor. There is a dining area, main lounge and two smaller lounges which are quieter. There is a large well-tended garden to the rear of the property.

Brownlow House was last inspected in August 2017 where we found a breach in regulation 12 as medicines were not always managed safely. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe and well led to at least good.

At this inspection we found medicines were now safely managed and administered as prescribed. Detailed guidelines were in place for medicines that were not routinely administered and staff recorded when thickeners were added to people’s fluids to reduce the risk of choking. We have made a recommendation for good practice guidelines to be followed for recording variable dose medication.

A registered manager was in place at Brownlow House. Since our last inspection the registered manager had also registered for a nearby sister home and was responsible for both homes. 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 this inspection we found breaches in regulations for good governance, premises and staff training.

Between December 2017 and May 2018, the registered manager had not had full oversight of Brownlow House. They had spent the majority of this period at the sister home they are also responsible for.

Internal audits from May 2018 showed the home was cluttered, not clean and there was a smell of urine. The local authority visited in July 2018 and found the same issues. An urgent action plan was put in place and improvements were made. However, at this inspection there continued to be a malodour on the first and second floors. The provider had not acted in a timely manner to replace carpets in these parts of the home to manage the odour.

The registered manager had recently introduced additional quality assurance tools to monitor the service.

Pre-employment checks were completed. Evidence that gaps in two candidate’s employment histories was not available in the staff files on the day of our inspection. Undated interview notes explaining the gaps in employment for one person were sent following the inspection and we were told they had also been made for the other employee, but the service was unable to locate them. Existing staff received the training they required to carry out their role. However, new staff started working at the home before completing training and with minimal induction shifts to get to know people and their needs.

Our inspection in August 2017 found improvements had been made following our inspection in July 2016. However, the service had not been able to sustain these improvements with the issues with training for new staff and maintenance at the home again found at this inspection, as they had been in July 2016.

Care plans and risk assessments were in place that reflected people’s current needs and provided guidance for the care staff in how to meet the identified needs. We have made a recommendation to follow good practice and include all relevant information within the care plans themselves so it is easier for staff to access the information they need.

The home referred all people who may lack capacity to the local authority for a formal capacity assessment. Where people were judged to lack capacity to consent to their care and treatment an application was made for a Deprivation of Liberty Safeguards (DoLS). We have made a recommendation for the home to follow best practice guidelines for assessing and recording people’s capacity to make specific decisions.

Incidents and accidents were recorded and reviewed by the registered manager. However, the records of two incidents involving one person were not consistent with photographs of the bruising sustained. The local authority safeguarding investigation found that whilst the home had an appropriate safeguarding policy and procedure in place, this had not been followed.

We had been made aware of an issue with some people’s money that was currently under investigation by the police. The home had changed their procedures for managing people’s money, with one person from the central administration team (based at the nearby sister home) keeping bank cards and pin numbers on people’s behalf where they were not able to do this for themselves.

People said they felt safe living at Brownlow House. Staff were aware of the safeguarding procedures at the home. There were sufficient staff on duty to meet people’s assessed needs. Staff knew people’s needs and their likes and dislikes.

An activities co-ordinator had been recruited and worked three afternoons per week. People enjoyed these activities. Some people went out to the local community with the activities co-ordinator; however, other people said they did not get the opportunity to go out as the staff were not able to go with them.

People were supported to maintain their health and nutrition. Medical professionals we spoke with were positive about the home and said they made referrals to them in a timely manner.

Staff said they enjoyed working at Brownlow House and felt well supported by the registered and deputy managers. Staff had regular supervisions and staff meetings were held.

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.

Brownlow House is registered to provide accommodation, support and personal care for up to 31 people. The home provides support for people living with dementia or a mental health issue. The home works with people who have had a history of abusing alcohol.

At the time of our inspection 29 people were living at Brownlow House. Twenty eight people had their own room and two people wished to share one room. Brownlow House is an older building with three floors, accessed by a lift. People used shared bathrooms on each floor. There is a dining area, main lounge and two smaller lounges which are quieter. There is a large well-tended garden to the rear of the property.

The service had a registered manager in place as required by their Care Quality Commission (CQC) registration. 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 registered manager was supported by a deputy manager.

At our last inspection we found two breaches of the Health and Social Care Act 2008 regarding medicines management and the maintenance and decoration of the home. Following this inspection the provider was required to submit an action plan to the Care Quality Commission (CQC) outlining how they would meet the regulations. An action plan was submitted for the breach in medicines management; however an action plan was not submitted upon request, regarding the maintenance and decoration of the home. The CQC wrote more formally to the provider, at their request, following their initial response to clarify for them the legal position in relation to the submission of action plans. A response to this was received and improvements implemented.

At this inspection we found improvements had been made within the home. Repairs had been completed, new carpets and flooring laid and rooms re-decorated. New furniture had been purchased for the lounges and people’s bedrooms. The doors on the lift at the home were damaged, although it had been passed as serviceable by a specialist lift company. Following the inspection the provider told us they were planning to replace or repair the lift doors.

People received their oral medicines as prescribed and the medicine administration records (MARs) charts were fully completed. We found prescribed topical creams were applied by the care staff but the MAR was signed by the senior staff. Where people had been assessed as at risk of choking thickeners were added to fluids. The staff did not sign a MAR or other chart to state that they had done this. The deputy manager said they would design and implement charts for topical creams and thickeners for staff to sign when they applied the cream or added the thickener to fluids.

Protocols for when ‘as required’ medicines should be administered were not always in place. Liquid medicines and creams were not dated on opening as per good practice guidelines.

People we spoke with said they liked living at Brownlow House and felt safe. They were complimentary about the staff team. People said the staff treated them with kindness and respect and knew their needs well. We heard and saw positive interactions between people and staff members throughout the inspection.

People said there were enough staff to support them within the home, but they were not supported to access the local community very often. The registered manager told us they ensured people were supported to attend medical appointments.

We saw the number of activities arranged within the home had increased since our last inspection. A weekly programme of activities was available and external entertainers visited the home.

Care plans were written in a person centred way and identified the support required to meet people’s health and social are needs. We saw risks were identified and guidance given to staff to mitigate these risks. However, one care plan we saw stated staff were to monitor for signs that a person’s mental health was changing, but the care plan did not detail what these changes might be. When we spoke with staff they were able to describe people’s needs and the signs to be aware of that people’s mental health may be changing.

Senior staff completed a handover at the start of each shift. This provided information about any changes in people’s health and wellbeing. The seniors then informed the care staff working on the shift of the relevant information. One staff member said this worked okay; however another said they sometimes got information later in the shift as they were busy supporting people in the morning.

A system of recruitment was in place with checks being made to ensure applicants were suitable to work with vulnerable people. However, full employment records were not always provided. We have made a recommendation that best practice guidelines are followed for ensuring full employment histories are recorded and the reason for any gaps in applicants’ employment were explained.

Staff had completed training the service considered mandatory. Staff had completed or were enrolled on the care certificate. Experienced staff had completed a nationally recognised qualification in health and social care. Staff were being enrolled on specific courses to meet the needs of people living at Brownlow House such as dementia and managing challenging behaviour.

Staff said they felt supported by the registered manager and deputy manager. Staff had supervisions and regular team meetings were held. Staff said they were able to discuss any issues or concerns they had. This meant the staff received the training and support to meet people’s health and social care needs.

Systems were in place to meet people’s health and nutritional needs. People were regularly weighed in line with their assessed risk and we found evidence of referrals made to the Speech and Language Team (SALT), district nurses and other medical professionals as needed. Medical professionals told us the service made appropriate referrals and followed any advice they were given.

Mental capacity assessments had been completed and applications for a Deprivation of Liberty Safeguards made to the local authority where required. People confirmed the staff gave them choices over day to day decisions and supported them to complete the tasks they could do for themselves so that they maintained their independence. Staff knew who was able to access the local community on their own and would open the door for them when asked. A record was kept of when people left and returned to the home.

All accidents and incidents were recorded and then reviewed by the registered manager. One notification to the CQC had not been made during a period when the registered manager was not in work. Since our inspection appropriate notifications have been received.

A range of audits was in place, including health and safety, mattress audits and medicines.

The home was clean throughout. However there was a malodour on the ground and top floors. New flooring was due to be laid on the top floor which should help eliminate this.

The home was registered with the Six Steps programme for end of life care. Information had been provided to people about making plans for their end of life care. We were told many people did not want to discuss this subject; however this was not recorded in the care files.

Systems were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity and gas supply. Regular checks were in place of the fire systems and equipment.

Regular resident meetings were held where people were asked for their feedback on the service. A resident survey had been completed and a relative’s survey had just been issued at the time of our inspection. The replies received were positive about the home.

Brownlow House is registered to provide accommodation, support and personal care for up to 31 people. The home provides support for people living with dementia or a mental health issue. The home works with people who have had a history of abusing alcohol.

At the time of our inspection 30 people were living at Brownlow House. Twenty eight people had their own room and two people wished to share one room. Brownlow House is an old building with three floors, accessed by a lift. People used shared bathrooms on each floor. There is a dining area, main lounge and two smaller lounges which are quieter. There is a large garden to the rear of the property.

The service had a registered manager in place as required by their Care Quality Commission (CQC) registration. 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 told us they felt safe living at Brownlow House and had no concerns about the care and support they received. Staff had received training in safeguarding adults and knew the correct action to take if they witnessed or suspected abuse. Staff were confident that the registered manager would act on any concerns raised.

Existing staff received the training and supervision they required to be able to deliver effective care. Staff were supported to complete a nationally recognised qualification in health and social care. However we found new staff were not always provided with the mandatory training as soon as they joined the service. They were supported by experienced colleagues and the deputy manager was their mentor to guide them about the support people required.

A robust system of recruitment was in place to ensure staff were suitable to support vulnerable adults. We saw there were sufficient staff on duty to meet people’s daily needs. However the staff did not have time to organise regular activities for people or to support them to access their local community. Some people were independent and could go out of the home by themselves.

We saw medicines were administered by trained staff. However we saw that creams had not been dated when opened which meant people may be administered creams that had been open longer than the manufacturer’s instructions. The registered manager said all opened creams were returned to the pharmacy every four weeks. Two people had run out of ‘as required’ pain relief medicine. We were told the GP did not want to prescribe additional medicines; however this had not been recorded. Homely remedies were used when ‘as required’ pain relief had not been prescribed; however no homely remedies were available at the time of our inspection.This meant they may have been in pain and discomfort because the required pain relief medicines were not available. Guidelines for when people needed ‘as required’ medicines were being written during our inspection.

We found the home to be in need of maintenance and re-decoration. The home was clean. One bedroom had a malodour; all other areas of the home were free from odours. Procedures were in place to prevent and control the spread of infection. Systems were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity and gas supply. Regular checks were in place for fire systems and equipment.

People told us they received the care they needed. Care records were personalised and identified risks and people’s needs. Guidance for staff was included in the care plans. Information about people’s background, likes and dislikes were recorded in a one page profile for two out of the three files we reviewed. The care records were reviewed monthly and updated as required.

Systems were in place to help ensure people’s health and nutritional needs were met. Records we reviewed showed that staff contacted relevant health professionals to help ensure people received the care and treatment they required.

We found the service was working within the principles of the Mental Capacity Act (2005). Best interest meetings and capacity assessments were held where required. Applications for Deprivation of Liberty Safeguards (DoLS) were appropriately made.

People we spoke with told us that the staff at Brownlow House were kind and caring. During the inspection we observed kind and respectful interactions between staff and people who used the service. Staff showed they had a good understanding of the needs of people who used the service.

The service was registered with the Six Steps end of life programme. We saw people were supported to discuss their wishes for their care at the end of their lives.

Staff told us they enjoyed working in the service and received good support from the registered manager and senior care workers. Regular staff meetings took place and staff said they were able to make suggestions and raise any concerns they had at the meetings.

There were systems in place to investigate and respond to any complaints received by the service.

Residents’ meetings were held to enable people to comment on the care provided at the home. Relatives’ meetings had been arranged but no one had attended. Surveys had been distributed, however few completed forms had been received. All the people we spoke with told us they would feel confident to raise any concerns they might have with the manager.

The policies and procedures in use at the service were not dated, the registered manager said they were current, had been reviewed and updated policies were re-printed when they had been changed.

We noted there were a number of quality audits in the service; these included medicines, care records and health and safety. Actions were identified following the audits. We saw plans were in place to improve the care records, agree personal goals with people and complete the re-decoration and maintenance work at the home. However the service had been slow to implement these plans.

During this inspection we found breaches of Regulations 12 and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because improvements were required in the management of medicines and the building required maintenance and re-decoration work to be completed. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

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

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe and well cared for.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The home had appropriate policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people would be safeguarded as required.

Recruitment practice was safe and thorough. No staff had been subject to disciplinary action. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

There was an advocacy service available if people needed it, this meant that when required people could access additional support.

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Consent was sought before any intervention was carried out. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Comments made were positive about the service.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly. People were actively involved with their local community.

People were aware of how to make a complaint about the service.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

The provider sent us an action plan which outlined what had been done to improve the overall standard of the environment. This showed the provider had taken steps to address our concerns.

'The carers are good to me. I'm looked after very well. My brother picks me up every Wednesday to go to his house, and he thinks this is a good place for me to live.'

'They look after me well. I can go out when I want to. I have nothing to complain about. I couldn't wish for a better place.'

'I know what's going on, the staff tell me, and I can join in with any activities if I want to. They are really good to me.'

A relative of one of the people who used the service said, 'My relative gets on really well with the staff. They show that they are concerned about her.'

People's care needs were recorded in an individual plan of care. This was reviewed regularly to ensure it accurately reflected people's current care needs. A range of helath care professionals were consulted with to ensure people's holistic care needs were met.

A complaint procedure was available so the people who used the service knew what to do if they were unhappy with the standard of care they received.

Some improvements needed to be made to the fabric of the building to ensure a more comfortable environment was provided for the people who used the service.

We observed people eating their food at lunch time. People who needed assistance were appropriately supported by members of staff. The people we spoke with at lunch time told us they enjoyed the food. One person said 'I like the food. We get a choice in the morning now of what we want to eat for lunch. It is usually ok.'

People told us there are often activities to do. One person said they liked to keep busy and enjoyed sometimes helping with tasks in the home, which they were supported to do by the staff.