CQC report explained · a residential care home
What the CQC found at Bryn Haven
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2020
Inspected but not rated; the home had improved falls checks and infection control, but investigations and management oversight were not always reliable.
This was a targeted inspection on 8 and 9 October 2020. Inspectors checked concerns about falls and also reviewed infection prevention and control during the coronavirus pandemic. They spoke with managers and examined risk assessments, care plans, daily records, incident forms, training data and quality checks.
Inspectors found that falls risks were being assessed and reviewed. People identified as being at high risk had extra checks, suitable equipment and referrals to a GP for additional health checks. Staff responded appropriately after falls. Infection control arrangements were also considered suitable.
However, the home did not always investigate falls or learn from them promptly. Some required referrals were not made, and records did not always clearly show aftercare or professional visits. The provider's systems did not give managers a clear enough overview.
The service was inspected but not rated at this visit. Its previous overall rating of Good remained unchanged because this inspection did not cover the whole service or all parts of the key questions.
Falls risk checks
People's falls risks were reviewed, and the new manager had assessed mobility and falls risks individually.
“Risk assessments were reviewed regularly and updated following a fall.” from the report
Practical safety measures
People at risk had access to suitable equipment, and staff had training that included falls prevention.
“People had access to appropriate equipment. For example, sensor mats had been placed in people's bedrooms, where required.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for PPE, testing, visitors, distancing and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Care after falls
Staff responded appropriately when people fell, even though the records of what happened afterwards were not always detailed.
“Staff had responded appropriately to care for people when they had fallen.” from the report
Falls were not always investigated
needs fixingThe home did not consistently investigate falls or use them to prevent further incidents. One person had several falls before a more serious fall.
“Investigations into falls were not always completed. One person had fallen twice within a two-week period and did not sustain any injuries.” from the report
Slow implementation of improvements
needs fixingActions following the coroner's recommendations were put fully in place slowly. An outdated falls policy was still available to staff on the first day of inspection.
“Whilst we saw that some of these actions had been carried through, the provider did not formally update and fully implement the falls prevention policy, the falls pathway and their improved audit system until August 2020.” from the report
Referrals and records
needs fixingSome people who had repeated falls were not referred to healthcare professionals as expected. Records did not always clearly capture referrals, aftercare or professional visits.
“Under the improvements indicated in the provider's Regulation 28 response to Her Majesty's Coroner in January 2020 these falls should have triggered a referral to a healthcare professional.” from the report
- 01How do you now investigate every fall, including repeated falls that do not cause an injury?
- 02How do you make sure people with repeated falls are referred promptly to the right healthcare professional?
- 03How do you check that the updated falls prevention policy and falls pathway are being followed by staff?
- 04How are aftercare, professional visits and monitoring recorded and reviewed?
- 05What audits are now completed, and how do managers act when the audits identify a problem?
This was a targeted inspection of specific concerns about falls, together with infection prevention and control; Safe and Well-led were inspected but not rated, and the previous overall Good rating remained unchanged. This explanation was written from the published report of 13 November 2020 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, June 2018
Bryn Haven was rated Good; inspectors found safe, kind and personalised care, with staffing calculations needing clearer evidence.
This was a two-day inspection on 6 and 15 March 2018. The first visit was unannounced. Inspectors observed care, spoke with people living there, visitors and staff, and reviewed care records, medicines, recruitment files, training records and quality checks.
The home had improved since the previous inspection in January 2016, when it was rated Requires Improvement and had six breaches of regulations. At this inspection, inspectors found the improvements had been made and found no new breaches.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and well cared for. Inspectors found clean surroundings, safe medicines management, trained staff, respectful care, personalised activities and detailed monitoring of the service.
Improved safety
Medicines, risk assessments, infection control and environmental checks had improved since the previous inspection. Inspectors found no discrepancies in their sample medicine checks.
“At this inspection we found improvements to the service and no further breaches to the regulations.” from the report
Kind and respectful care
Staff supported people calmly and sensitively. Inspectors saw privacy and dignity being respected, including doors being closed during personal care.
“We observed staff interactions with people and we saw staff were good at respecting people's privacy and dignity.” from the report
Personalised activities
Activities reflected people's interests and included outings, a dementia group and community events. The home also used visual signs and reminders to help people with dementia find their way around.
“We saw that people were assisted to engage in a variety of meaningful activities of their choosing.” from the report
Strong quality monitoring
The management team used detailed audits covering areas such as care records, training, safeguarding, complaints and medicines.
“The provider had developed in depth internal inspections offering detailed oversight and evidence of clear auditing records to show on-going governance of the service.” from the report
Staffing evidence
needs fixingStaffing levels were consistent with what inspectors were told, and people did not appear to wait for long periods. However, the provider could not show through a staffing calculator how staffing hours were linked to people's assessed and changing needs.
“The registered provider did not use a staffing calculator to show how the staffing hours were calculated to meet the assessed dependencies of people living at the service.” from the report
Care records being transferred
minorThe home was moving care records to a new format. Some records had been transferred, while others were still being updated, so families should ask whether this work is now complete.
“Some records had been transferred and some were still in the process of being updated.” from the report
- 01How do you now calculate staffing levels for each shift, and how do you adjust them when people's needs change?
- 02Has the move to the new computerised care-record system been completed for everyone?
- 03How do you check that medicines continue to be given safely and as prescribed?
- 04What activities and outings would be available for my relative, based on their interests and abilities?
- 05How are families involved in reviewing care plans and raising concerns?
This was an overall inspection checking improvements after the previous Requires Improvement rating and reviewing all five key questions. This explanation was written from the published report of 28 June 2018 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 Bryn Haven
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- November 2020Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- June 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
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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Most charge £980 to £1,260 a week. 88 can care for a couple. 10 years' experience on average.
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