Bramley House Residential Home

Bramley House is a residential care home providing accommodation and personal care to up to 16 people in an adapted building. The service provides support to older people, some of who may be living with dementia. At the time of our inspection there were 15 people using the service.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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. However, we found the principles of the Mental Capacity Act 2005 were not fully embedded into practice. We have made a recommendation in relation to this. There was no evidence this was impacting on people’s lives.

People’s care was personalised and people told us they felt at home. Staff knew people’s needs, life histories and preferences well. Whilst people received the care they required, care plans were not always updated promptly and audits had not been completed to monitor this. The registered manager and provider told us they were aware of this and were implementing changes to the systems used to address this.

People told us they felt safe in their home and staff were aware of their responsibilities to report safeguarding concerns. Risks to people’s safety and well-being were assessed and monitored to ensure they received the support they needed. Infection control procedures were in place and training had been completed by staff. Safe medicines practices were followed and people received their medicines in line with their prescriptions. The environment was designed to meet people’s needs and regular health and safety checks were completed.

There were sufficient staff available to support people safely. People told us they felt staff were competent in their roles and they did not have to wait for their care. They described Bramley House as being a home from home and said they were treated respectfully. Staff had a kind and caring approach and knew people well. We observed easy conversations and people appeared relaxed in the company of staff. Activities were developed in line with people’s interests and people were supported to go out should they wish to do so. Visitors were welcomed to Bramley House and people were supported to maintain links with friends and family.

The majority of people told us they enjoyed their food and people’s individual preferences were catered for. Where people required support to eat this was provided in a safe and dignified way. People had access to healthcare professionals when required and healthcare needs were monitored.

There was a positive culture within the home with a commitment to providing a homely and personalised service to people. The management team were highly visible and people and staff felt they were approachable and supportive. The registered manager and provider continued to look at ways to develop the service and to provide new opportunities for people.

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

Rating at last inspection

The last rating for this service was good (published 22 August 2018).

Why we inspected

The inspection was prompted in part due to historic concerns received about the support people received when eating and how guidance from professionals relating to this was followed. A decision was made for us to inspect and examine those risks. During the inspection we did not identify concerns in this area. People were supported appropriately and staff were fully aware of people’s needs.

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.

Follow up

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

The service had a registered manager in post. 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.

We last inspected this service on 15 July 2017. At that time we identified a breach of legal requirements relating to the management of records within the service. We took enforcement action following this inspection as we had previously identified shortfalls in record keeping during inspections to this service. Following the inspection the registered provider sent us an action plan telling us they planned to address this shortfall. We used this inspection to check whether the registered provider had taken action in line with their action plan.

Bramley House is a small service which is friendly and homely. People were cared for by a small number of staff who knew people well and delivered a person-centred care. People’s choices and opinions were valued and they were actively involved in making decisions about their care.

Staff showed kindness and compassion. People’s dignity and independence was promoted by staff who also showed respect towards the people they cared for. People were cared for by a sufficient number of staff to meet their needs.

People felt safe and staff were aware of safeguarding procedures should any suspected abuse take place. Staff had adequate training and experience to care for people safely. The appropriate recruitment processes and ongoing monitoring of staff ensured that only suitable people worked at the service.

Medicines were managed safely and there were effective infection control procedures. We saw evidence that lessons had been learned when things had gone wrong by adopting procedures to prevent incidents happening again. Risks to people had been identified and plans were in place to help reduce those risks.

People’s care plans took into account their wishes and preferences. People’s needs were assessed and the care people received reflected the needs identified in the assessment. End of life wishes for people had been considered. People had access to a range of activities and they told us if they were unhappy with any aspect of the service they would know who to speak to.

People were provided with a choice of food and drink throughout the day and were supported to maintain their nutrition and hydration needs. People’s health was promoted by access to healthcare services.

The home was well adapted and designed to meet people’s individual needs. Staff followed the principals of the Mental Capacity Act 2005 in relation to people’s consent and any restrictions that may be placed on them.

People and staff praised the registered manager. Staff felt that they were supportive and approachable and people liked the open, welcoming culture of the home. There was effective communication between management, staff, people and their relatives.

There were quality assurance systems in place to identify where improvements were needed. The service worked in partnership with other agencies to deliver joined-up care.

The inspection took place on 15 July 2017 and was unannounced.

The registered manager was present for part of our 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 2008 and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection of this service on 15 June 2016. At that inspection we identified two breaches of legal requirements relating to the management of records within the service. We undertook a follow-up inspection on 3 May 2017 to check that the provider had taken the action they told us they had. At that time we found that the legal requirements had been met.

Since our last inspection we received some concerns about the service. In particular, we were informed that people may not always receive safe care at weekends and that records were not always an accurate reflection of the care provided at the service. Some concerns are still being investigated under a wider safeguarding investigation and as such we are not able to comment on these at this time. We are working in partnership with other agencies and will continue to respond to any new information which indicates that Regulations may have been breached.

Our findings from this inspection have been included under two key questions: is the service Safe and is the service Well-Led? You can read the report from our previous inspections, by selecting the 'all reports' link for Bramley House Residential Home on our website at www.cqc.org.uk”.

At this inspection we found that records about the care people provided were not always an accurate reflection of the support they had actually received. Staff had an excellent knowledge of people’s support needs and were able to describe the care people needed each day. This knowledge however was not fully reflected in people’s care plans and in some cases information recorded in one part of the care plan was different to that recorded in another. Through discussions with people, staff and management it was clear that changes to people’s needs had been responded to, but the records in place had not always been updated to evidence this.

Some records were completed retrospectively, rather than at the point support was provided. When we arrived at the service, the Medication Administration Records (MAR charts) did not reflect that people had received their medicines that morning. Discussion with staff, people and a review of the medicines trolley confirmed that people had received their medicines as prescribed. There was little risk of people being given their medicines again because only the staff member in charge of the shift handled medicines.

Internal audits had identified that some of the records were not being completed as required. Whilst this issue had been raised and discussed within the staff team, it had not secured the necessary improvements. The compliance with the legal requirements around record keeping that we found in May 2017 had therefore not been sustained.

The failure to maintain accurate records however was a breach of Regulations.

People’s needs were met by a small number of staff who worked effectively together as a team. Staff were aware of the systems in place if people were unwell, injured or at risk of harm. People received safe care that was personalised to their individual needs and choices.

The inspection took place on 3 May 2017 and was announced.

The home had a registered manager. 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.

We carried out an unannounced comprehensive inspection of this service on 15 June 2016. Two breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to maintaining appropriate records and ensuring legal notifications to us were submitted in a timely way. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This inspection found that the provider had taken the action they told us they had. This report only covers our findings in relation to the leadership of the service. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bramley House Residential Home on our website at www.cqc.org.uk”.

Since our last inspection, the person in charge of the daily running of the service has been registered as the manager for Bramley House. The new registered manager was in the process of completing a relevant management course. They had also taken responsibility for ensuring that all statutory notifications are submitted in line with legal requirements.

The management and staffing team at Bramley House had worked hard to improve the standard of record keeping across the service. As such, we found that records were now a much better reflection of the support provided to people. Care plans and risk assessments now provided more information to ensure that new and temporary staff were able to deliver care in the same way as those staff who worked more regularly at the service.

There were systems in place to regularly audit and improve the service delivered. People and their representatives were encouraged to share their views and were routinely consulted about proposed changes and developments for the service.

The inspection took place over two days on 15 June 2016 and 20 June 2016. The first inspection day was unannounced.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 inspection identified that the current registered manager, who is also the provider of Bramley House, was no longer in day to day charge of the home. They have therefore agreed that the person who does manage the home will now apply to be registered with us.

Bramley House is a friendly and inclusive service that provides people with support in a ‘home from home’ environment. People were central to the care that was provided. The provider had deliberately kept the service small so as to ensure a truly person centred experience of care. The standard of record keeping at the service however did not accurately reflect the quality of care provided. In particular, whilst people received appropriate care, their care plans and risk assessments did not always provide sufficient information to demonstrate how decisions had been made or how care was provided consistently.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The service had experienced issues with its computer systems earlier in the year. They did not inform us of this issue and therefore correspondence requesting they complete an appraisal of their service we sent to them was not received. They also did not submit a notification to us that they were legally required to do.

The home had a no locked door policy and provided support to people in the least restrictive way. Prior to offering a permanent place to people, the management and staff team undertook a minimum two week assessment of people’s needs. This was to ensure that people’s needs could be appropriately met at Bramley House.

People’s needs were met by a small number of staff who worked effectively together as a team. The appropriate recruitment and on-going monitoring and appraisal of staff had ensured that only suitable staff worked at the service.

Staff received training and support from the management team in order to deliver their roles and responsibilities in line with best practice. People were protected by the systems in place to safeguard people from the risk of harm or abuse.

People had good relationships with staff who took steps to ensure care was provided in a way that protected their privacy and dignity. People were encouraged and supported to both maintain and develop their independence and spend their time doing things that were meaningful to them.

People were supported to maintain good health and there were systems in place to ensure their medicines were managed safely. People had choice and control over their meals and were effectively supported to maintain a healthy and balanced diet.

People were actively involved in making decisions about their care and these choices were effectively communicated and respected by staff. People and their representatives were able to share their feelings and staff ensured that when people raised issues that they were listened to and people’s opinions were valued.

At this inspection, in addition to inspecting in other areas, we also reviewed the actions the provider had taken in response to the compliance action. We found that the provider had met the previous compliance action.

During our inspection we set out to answer our five questions; Is the service safe?, Is the service effective?, Is the service caring?, Is the service responsive?, Is the service well led?

Below is a summary of what we found. The summary is based on our observations during our visit, discussions with people who used the service, their relatives, the staff supporting them and looking at records.

Is the service safe?

We found the service provided safe and appropriate care and had identified risks to people who used the service. As a result people's safety was ensured as plans were put in place to manage the risks identified. Staff were aware of the safeguarding procedures and had received training to ensure they had the most up to date guidance in relation to this. People who used the service told us they had no complaints and felt safe at the home.

We found that that the concerns identified in the previous inspection in relation to the environment had been addressed.

Is the service effective?

All the people who used the service told us the home was a 'Lovely place' and they 'Liked' being there. People's health and care needs were assessed with them, and people who used the service told us that they were involved in their care plans. We observed that people could move around the home and grounds freely and independently or with support if they needed this. We saw that staff promoted people's independence and gave people the level of support they wanted, with knowledge and practices that reflected the care plan.

Is the service caring?

We saw that people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's care plan.

We observed staff took time to make sure that people were not hurried or rushed. We saw that people were relaxed and that interactions with staff were positive.

Is the service responsive?

We found that the service responded appropriately to any risks to peoples safety. For example one person moved furniture on their own and the service responded to this by making sure that they monitored that this person did not put themselves at harm or risk of harm.

We saw that if people's needs could no longer be met by the service then this was identified promptly so that the appropriate care could be provided. The service responded to comments and complaints and had regular meetings to make sure that they met people's needs.

Is the service well-led?

People who used the service told us they had no complaints about the service. The service had made the necessary improvements to ensure that people were safe and responded in a timely manner.

We saw that the provider attended the service on a regular basis to keep updated and in touch with how the home was running. We spoke with the manager who demonstrated knowledge of the maintenance needs of the home identified in the last report and an awareness of risks so they could be managed to keep people as safe as possible. For example some windows had been replaced due to their poor condition.

People told us the staff were nice and treated them with respect. They said they were offered choices, the food was good and they could have an alternative if they didn't like the menu. One person told us they had seen that some people get special diets and that everyone was catered for here.

People also told us their room was not too hot or cold and they liked their rooms and the home.

Two people that we were speaking to in a group said they felt listened to, had no complaints and agreed they couldn't fault the home.

We saw that care and treatment was planned and delivered in a way that ensured people's safety and welfare.

We concluded that people who use the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises. This was because the provider had not maintained water supplies for washing and bathing to safe working temperatures; not managed identified asbestoses safely; had left, chemical and sharps hazards accessible to people; had not fitted sufficiently robust window restrictors and had not ensured windows were secure or safe. They also had not ensured all doors had expanding smoke strips to slow the spread of smoke during a fire; had not protected staff from passive smoking; and had left unsupervised areas that contained tripping hazards, steep short stairs and hazardous chemicals, unsecured and accessible to people.

Although we found concerns there were areas of good practice with the environment. It has been kept an open environment so that people are not affected by people misplaced or whose needs require more security and restrictions for their safety due to their lack of capacity. We saw that people were offered a choice of a bath being fitted in shower rooms. We also saw that the environment was homely, hygienic and clean, even before the manager arrived early in the morning when we visited unannounced.

We saw the provider had an effective system to regularly assess and monitor the quality of service that people receive.

People had care plans in place that were up to date, which they were consulted about. The home had completed some risk assessments but they had not completed nutritional screening assessments.

Staff received training and supervision to be able to meet the needs of people living in the home.

Although the service provided a comfortable and homely environment to live in we found some areas of potential safety risks to people who used the service.

Feedback surveys had not been distributed recently to gain the views of people who used the service about the quality of the service provided.

People who used the service told us that they would feel to raise any concerns if they had any. A person said "The staff are very good listeners'. Some people who used the service said they were not aware of the home's written complaints procedure.