CQC report explained · a residential care home
What the CQC found at Breagha House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were times when staffing was below the required level, putting people at risk of not receiving the support they needed. Inspectors found improvements in safeguarding, risk management, medicines, infection control and learning from incidents.
- Effective?
- Good
- People's needs and choices were assessed, and staff had improved training and guidance. People were supported with food, healthcare, communication, consent and least restrictive care.
- Caring?
- Good
- No rating was given for Caring in this inspection.
- Responsive?
- Good
- No rating was given for Responsive in this inspection.
- Well-led?
- Good
- Leadership and quality monitoring had improved. However, records showing the training and induction of agency staff were spread across systems and were not consistently robust.
What inspectors found, December 2021
Breagha House was rated Requires Improvement; staffing was not always sufficient, but the home improved and left special measures.
This was an unannounced follow-up inspection on 13 and 21 October 2021. Two inspectors spoke with people, staff and relatives, observed care, and checked care records, medicines, training and quality checks. They also sought information from the local authority and advocacy services.
The overall rating was Requires Improvement. Safe was Requires Improvement. Effective and well-led were Good. The main problem was that staffing levels sometimes fell below what people had been assessed as needing. In October, records showed 25 days and 10 nights when staffing was below the required hours.
There had been substantial improvement since the previous rating of Inadequate. Inspectors found improvements in safeguarding, risk management, medicines, infection control, person-centred care, nutrition, healthcare access and management oversight. The home was no longer in special measures, although CQC said it would continue to monitor progress.
Improved leadership
Relatives had more confidence in the manager and staff understood their roles. The provider shared an improvement plan with CQC and worked with the local authority.
“The leadership of the service had improved since our last inspection.” from the report
Safer medicines
Inspectors found that prescribed and as-needed medicines were documented, given and disposed of safely. Staff had medicines training and competency checks.
“People received their prescribed medicines safely.” from the report
Better risk management
People's health risks were recorded and reviewed. Environmental checks, emergency plans and personal evacuation plans had also improved.
“People's needs were assessed, and any risks associated with their health conditions documented.” from the report
Support for individual needs
Care plans included people's communication styles, dietary needs and health needs. Staff used visual communication and signing where appropriate.
“Each person had information about their individual communication styles in their care plans, and staff knew how to support each person with their communication.” from the report
Staffing shortages
seriousThere were not always enough staff to keep people safe or provide the individual support they had been assessed as needing. Records showed shortages on many days and nights in October 2021.
“There were not always enough staff to keep people safe or to provide them with the individual support they were assessed as needing.” from the report
Agency staff records
needs fixingThe home could not consistently show which agency staff had completed the training needed to support people. This created a risk that staff might not have the right skills.
“It was difficult for the provider to clearly identify which agency staff had received training necessary to support people” from the report
- 01How many staff are on each shift now, and how do you make sure one-to-one and two-to-one support is covered when there are absences?
- 02How many staffing shifts have fallen below the required level since the inspection in October 2021?
- 03How do you now record and check the training and induction of agency staff?
- 04Has the manager completed registration with CQC?
- 05Have the planned changes to the kitchen and dining areas been completed, and have they reduced noise and congestion?
This was a follow-up inspection that assessed Safe, Effective and Well-led; Caring and Responsive were not rated in the report. This explanation was written from the published report of 25 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2021
Breagha House was rated Inadequate and placed in special measures; inspectors found serious risks involving abuse, staffing, medicines, care planning and management.
This was an unannounced focused inspection on 10 February 2021 and 01 March 2021. Inspectors looked at Safe, Effective and Well-led because of concerns about staffing, medicines, safeguarding, restrictive care and management. They spoke with people and staff, observed care, and checked care records, medicines, training and quality checks.
Inspectors found people were at risk of abuse and neglect. There were not enough staff to provide planned one-to-one support. Risks were not properly assessed, medicines were not safely managed, infection control was not reliable, and the home did not consistently report or learn from incidents.
Inspectors also found that care was not consistently person-centred. Communication support, sensory needs, food choices, health appointments, consent and restrictive care were not managed properly. The home did have an action plan and had started making changes, but the provider could not show that its systems were working well.
The overall rating fell from Good at the previous inspection, published in September 2019, to Inadequate. The home was placed in special measures, meaning CQC would keep it under review and normally re-inspect within six months.
Recruitment checks
The provider carried out checks to help ensure staff were suitable for the work.
“The provider ensured staff were of good character and were fit to carry out their work.” from the report
Action plan
The provider had begun working with the local authority and commissioners and had created an action plan for improvement.
“The provider had developed a detailed action plan to improve all aspects of the service.” from the report
Personalised bedrooms
People were encouraged to make choices about their own bedrooms.
“People were encouraged to make choices about decorating their personal space, and their bedrooms were personalised.” from the report
Safeguarding
seriousAll ten people were being supported by the local authority in relation to allegations of abuse. Some concerns raised by staff were not acted on.
“People were not kept safe from the risk of abuse.” from the report
Staffing levels
seriousThere were not enough staff to provide the one-to-one or two-person support some people needed. Staff also lacked some required refresher training.
“There were not enough staff to keep people safe and provide the support they were assessed as needing.” from the report
Medicines
seriousMedicine records and stock counts were inaccurate. Staff did not have enough guidance about some medicines given when needed.
“People's medicines were not managed safely and people were at risk of not receiving their medicines as prescribed.” from the report
Care and communication
seriousCare plans did not consistently reflect people's needs, communication methods or sensory support. People were at risk of not being able to express their wishes effectively.
“People were not supported to communicate in ways which were meaningful to them.” from the report
Consent and restrictions
seriousCapacity assessments and records about restrictions did not clearly show how decisions were made in people's best interests. Guidance about physical restraint was not specific enough.
“Consent to care was not sought in line with legal requirements.” from the report
Quality management
seriousThe provider did not identify patterns in incidents or use quality checks effectively. It also failed to notify CQC consistently about significant events.
“Systems and processes to assess risk and monitor quality were insufficient and ineffective in driving improvements.” from the report
- 01How many staff are now on each shift, and how do you guarantee every person's planned one-to-one or two-person support?
- 02What checks now confirm that medicines are counted accurately, given as prescribed and reviewed when needed?
- 03How are safeguarding concerns reported, investigated and shared with the local authority and CQC?
- 04How do you make sure each person can communicate choices and consent using their required communication aids?
- 05What evidence can you show that incidents, restrictive care and quality checks are now reviewed and acted on?
This was a focused inspection of Safe, Effective and Well-led, with infection control included under Safe; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 3 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Breagha House
6 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
- September 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- September 2017Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- August 2013
Registered with the Care Quality Commission on 27 August 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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