We inspected Breage House on the 9 June 2017, the inspection was unannounced. Breage House is one of a number of services in Cornwall which are run by the provider, Keelex 176 Limited. Breage House provides accommodation for up to 16 people who have a learning disability. At the time of the inspection 12 people were living at the service.At the last inspection, in September 2016, the service was rated Good. At this inspection we identified two breaches of regulation and therefore the service is now rated as Requires Improvement.
This inspection was brought forward as we had received four anonymous concerns about the service. The concerns were in relation to how some staff approached some of the people they supported, and the staff team dynamics. We discussed these areas of concerns with the registered manager, and also spoke with staff members prior to, during and following the inspection.
It is acknowledged that the registered manager had only worked at the service for a few months and was getting to know the people, staff and service. Therefore some staff said they were not sure if they could approach the manager with concerns as their working relationship was developing. This had led to the commission receiving concerns about the service directly.
Eight out of nine care staff that we spoke with during this inspection process, told us relationships between certain members of the staff team were strained. Staff expressed concerns that there were “divides’” between the staff team and were fearful that this could impact on the care provided to the people they supported. Staff had lacked confidence in the service’s management but were hopeful that the appointment of the new registered manager would address these concerns. However, as yet they did not yet feel sufficiently confident to raise concerns directly with the new registered manager. They also hoped that the registered manager would provide a consistent management response to all staff. They felt this would then address the tensions between staff and that all would be treated fairly and be listened too.
Staff were concerned about the quality of food provided, its nutritional value and presentation. We observed at lunchtime that some people were given blended cheese on toast which had been made with brown bread. The presentation of this meal looked unappetising and one person queried the food until a staff member intervened, explained what it was and tasted it them self. The person was then encouraged to eat it. The cook was aware that the presentation of blended meals was unappetising. Due to this the registered manager had purchased some food moulds, which arrived during the inspection, so that this could be addressed.
A cook had recently been employed at the service but had not been provided with appropriate training or guidance on how to prepare food for people’s specific dietary needs. This meant that the meals were not presented in a manner that the person could choose or manage.
We reviewed the service’s menu for the week of our inspection and found that none of the meals were home cooked. The options available were unlikely to provide people with a balanced diet and lacked fresh fruit and vegetables.
We reviewed the kitchen documentation. Documents showed that kitchen had not been regularly cleaned in accordance with the cleaning schedule. The failure to ensure the cleanliness of food preparation areas exposed people to significant risks in relation to cross contamination and infection control.
People’s weight was not able to be monitored as the weighing scales had been moved to another care service. Therefore staff were unable to monitor people’s weight which could highlight potential changes to a person’s health and well-being. The registered manager and deputy manager acknowledged that weighing scales needed to be available at the service to ensure an overview of peoples dietary needs occurs.
We received concerns prior to the inspection about care practice that the staff had witnessed. This was investigated by the provider with the involvement of the safeguarding team and action had been taken to address the concerns raised.
People were supported to have choice and control of their lives. Where people did not have the capacity to make certain decisions, the service acted in accordance with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The manager had identified that bespoke training packages for individuals who may express behaviour in ways that challenge staff would be sought to ensure that people are cared for in the least restrictive way possible. This would be done in liaison with all relevant parties involved in the persons care.
We observed people had good relationships with staff and staff interacted with people in a kind and respectful manner. The staff team had developed caring and supportive relationships with people using the service. Relative’s comments about staff included, “Staff are so kind and helpful.” and “[Person’s name] likes to come home but also likes to go back to Breage, as they are happy there as much as at home.” People were supported to maintain contact with friends and family and had the opportunity to be involved in decisions about their care and the running of the service.
There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes. Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge.
Staff were supported through a system of induction and training. Staff told us the training was thorough and gave them confidence to carry out their role effectively. New employees undertook a rigorous induction programme and told us this was beneficial and prepared them well for their roles. A newly recruited member of staff told us, “I am new to care and the induction and training has been good.”
Care and support was provided by a consistent staff team, who knew people well and understood their needs. People were supported to access the local community and take part in a range of activities of their choice. Staff supported people individually and in groups to attend activities of their choosing.
Care records were up to date, had been reviewed, and accurately reflected people’s care and support needs. People had dedicated key workers who were responsible for updating care plans and leading on supporting people. These were chosen according to their experience and relationship with the person concerned. People, who received care, or their advocates, were involved in decisions about their support and consented to the care provided. Risk assessment procedures were designed to enable people to take risks while providing appropriate protection.
People were supported to maintain good health, have access to healthcare services and receive on-going healthcare support. Staff supported people to arrange and attend appointments to see their GP and other necessary healthcare appointments.
People and their families were given information about how to complain. Relatives told us they had no hesitation in raising any issues of concerns and were confident they would be listened too and appropriate action would be taken.
There were quality assurance systems in place. The majority of these were effective, for example in the areas of care planning, medicines and the environment. However some auditing process were not robust, as they had failed to identify the significant issues identified during the inspection in relation to food quality and the cleaning of the kitchen.