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Bramley House Residential Home Good

All reports

Inspection report

Date of Inspection: 5 March 2013
Date of Publication: 16 April 2013
Inspection Report published 16 April 2013 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 5 March 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We sent a questionnaire to people who use the service, talked with people who use the service and talked with staff.

Our judgement

The provider did not always have an effective system to regularly assess and monitor the quality of service that people receive.

The provider did not have an effective system in place to identify, assess and manage all risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

People who used the service and their representatives were asked for their views about their care and treatment but the outcome of this survey had not been analysed in order for the service to have an informed view of the standard of care that was being provided and to identify areas for improvement. We were told that the feedback survey was being reviewed and that it would contain more questions. This was due to be distributed shortly.

We saw that consultation meetings were held with people that enabled them to share their views about the service provided. Regular staff meetings were conducted. We saw information which confirmed this. The manager said that

all of the home's policies and procedures were in the process of being updated.

We saw that the home had a business development plan in place and the home was externally audited in 2011 using a system called 360 Forward Standard Framework. After this inspection we were provided with a progress report on the improvements that had been made as a result of the recommendations made. Examples included areas such as care planning, activities, staff training and premises improvement. We were told that this audit was due to be reassessed. However the home had not yet fully developed internal systems to assess and monitor the quality of the service provided and to identify, assess and manage all risks to the health, safety and welfare of people who use the service and others.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. We saw that incident and accident records were maintained. The manager told us that these were reviewed for trends and appropriate referrals were made for further advice where this was required. The provider may find it useful to note that these had not been signed by the manager or included written information to confirm what action that had been taken.