We carried out a review of the data available to us about Bramble Down on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Bramble Down, you can give feedback on this service.
Bramble Down is a care home providing personal care for up to 31 older people. At the time of the
inspection there were 30 people living at the home.
People's experience of using this service and what we found
Bramble Down House had a visible person-centred culture which ensured that staff in all roles were highly motivated and offered care and support that was compassionate and kind.
There was a good ethos within the service of treating people with dignity and respect. People were at the forefront of the service delivery and the provider was committed to and passionate about providing a good quality service. We received positive feedback from the majority of people and relatives. Any issues were already known by the service and were being addressed. The feedback reflected staff were kind, caring and committed. People complimented the continuity of care provided by regular staff, especially during the pandemic, which contributed to the building of meaningful relationships. Staff, supported by the activity team, recognised what was important to people and ensured an individually tailored approach that met people's personal needs, wishes and preferences were delivered.
Care and support plans were reviewed and changed as people's needs changed. The service worked closely with healthcare professionals. People were supported to maintain good health and to meet their nutritional needs.
Staff told us they were supported by the management team with empathy and understanding.
The registered manager, provider and management team provided supportive leadership and had developed a dedicated staff team who were committed to the vision and values of the service.
The provider had effective quality assurance systems, led by a quality assurance manager, in place which were used to drive improvement.
People living at Bramble Down told us they received safe care from skilled and knowledgeable staff. Staff knew how to identify and report any concerns. The provider had safe recruitment and selection processes in place. Risks to people's safety and well-being were managed through a risk management process.
There were sufficient staff deployed to meet people's needs, including over-recruitment during the pandemic.
Medicines were managed safely, and people received their medicines as prescribed.
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.
Rating at last inspection
The last rating for this service was requires improvement (published 4 December 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 12 Safe care and treatment and Regulation 17 Good governance.
Why we inspected
We looked at infection prevention and control measures under the Safe key question at the previous inspection. At that inspection we were assured that the service can respond to COVID-19 and other infection outbreaks effectively.
This inspection was carried out to follow up on action we told the provider to take at the last inspection. As a result, we undertook a focused inspection to review the key questions of Safe, Caring and Well Led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection and Infection Control and Prevention inspection, by selecting the ‘all reports’ link for Bramble Down on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
We found the following examples of good practice:
Visitors were only permitted by prior appointment. A new role of ‘Welcome Host’ ensured a positive greeting and staff facilitated visits to make sure they were as positive as possible. A clear visiting policy was communicated with families to ensure safe and enjoyable visiting as well as regular newsletters. Visitors were shown how to don and doff and a new screen and microphone had been purchased.
People and staff have been regularly tested to ensure they have not contracted COVID-19. Strict measures were in place to ensure people and staff would be isolated immediately if they had any symptoms of the virus, or if they had tested positive. Contingency and admission plans were clear. People and staff had received their Coronavirus vaccinations and had received support and information, including easy read, to help them feel comfortable with their decisions.
People had coped well during the pandemic due to a positive staff group and a good range of activities to suit individual interests, managed by three activity leaders. Staff hours had been enhanced to enable additional support. Staff were available to support visits using technology regularly. There had been many activities to keep people’s spirits up and maintain wellbeing; Christmas light display and a reindeer visit, carol singing outside, cooking club, arts and crafts club, Remembrance Day activities and celebrating BBC Music Day. The home had large grounds for people to use safely.
Safe procedures have been followed by staff to minimise the risk of transmitting COVID-19. They had good stocks of all personal protective equipment (PPE). There were supplies of PPE available around the home. Staff were seen using appropriate PPE. Staff had received training on donning and doffing and on the coronavirus pandemic from various sources including local health and social care professionals, e-learning and from in-house training sessions. Links with the wider social care community helped problem solving and sharing information. Staff were managed in cohorted teams with separate entrances and break spaces to further minimise the risk. Regular spot checks and walk arounds ensured guidance was followed. The service was involved in the new local Infection Control Champion training.
The home was clean and hygienic. Detailed cleaning schedules were in place for all areas of the home. All touch points were cleaned frequently including high touch points. Deep cleaning of all areas was carried out regularly. The home was well-ventilated and new cleaning products had been sourced for effectiveness.
The registered manager and providers acknowledged the staff team had been through a very difficult time and supported them to have regular time off, support and access to counselling if needed. The registered manager said the provider had been ‘brilliant’, even arranging for managers to access a psychiatrist which they found really helpful. Staff felt valued and appreciated, receiving regular support calls, bonusses and had received special treats as a thank you for their hard work.
Bramble Down is a residential care home providing nursing care. 27 people lived in the service at the time of the inspection. The service can support up to 40 people.
The service is on two floors, with access to the upper floor via stairs and lift. Bedrooms have en-suite facilities. There is a garden and courtyard outside.
People’s experience of using this service and what we found
People’s records identified their risk but there were not always clear plans in place to identify how these risks would be managed, reduced or mitigated. The service smelt fresh throughout. Some areas of the environment were clean. However, systems in place did not prevent or control the spread of infection. Medicines were not always managed safely.
People told us they felt safe and appeared comfortable when staff were with them. People told us staff were usually available when they needed them. Most people told us staff were kind and caring. People told us "We have a joke and a laugh” and “They’re very kind”. However, we observed several interactions between people and staff that did not show respect for the person.
Staff told us they had the skills and knowledge to meet people's needs effectively. All staff told us the training was good and they felt well supported. People told us they enjoyed the food at the service and described the food as, “Very nice” and “Amazing.”
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.
The service had introduced electronic care plans. Some of the care plans were very informative, others lacked person-centred information and appeared generic. The management team told us they were in the process of further developing the electronic care plans to be more person centred. Staff knew people well and were able to tell us about their preferences. People told us they were happy with the social activities, events and outings at the service.
There were some audit systems in place, however these had not always been effective in identifying where improvements were needed. The management team spoke openly and honestly throughout the inspection process. They told us they would start work immediately to make the required improvements that were needed within the service.
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 8 June 2017).
Enforcement
We have identified breaches in regulation relating to safe care and treatment, and governance at this inspection. We also made a recommendation in relation to evidencing people’s involvement in their care plans.
Please see the action we have told the provider to take at the end of this report.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The home is set over two floors, with a lift to access the first floor. It is set in the small rural village of Denbury. Accommodation is offered to people in single or shared rooms.
At the last inspection in January 2015 the home was rated as good in all areas. At this inspection we found the home remained good.
Why the service is rated Good
The home was being well managed and run. It was well resourced, which helped ensure there were suitable numbers of well trained and skilled staff to meet people’s needs. Where equipment or specialist training was needed this had been provided. The registered manager and provider had put in place systems and audits to ensure high standards were maintained at all times, and regularly updated their practice and knowledge so they could confidently set and oversee standards at the home. Effective quality assurance systems were in place, where people were able to contribute their views about the service.
People received safe care in an environment that was regularly reviewed for risks and actions were taken to reduce these where identified. These included assessments of potential risks from fire, hot water and infection control.
Risks to people’s health or well-being were assessed and mitigated through a series of risk assessments and actions taken to control them. This included assessments of people’s mobility, moving and positioning, nutrition, and any pressure ulcer prevention. These were regularly updated and specialist advice sought when needed.
People received their medicines safely, and people were protected because staff understood how to identify and report concerns or abuse. Systems were in place for the management of complaints and concerns, although most people told us they would just tell the registered manager if they had any concerns and would be confident they would be addressed.
People received care from staff who had been subject to a robust recruitment process. Systems for staff training and support ensured staff received the training and support they needed to fulfil their job role. We saw and people told us that staff had built positive and valued relationships with people and supported them to be as independent as they were able. A relative told us they had placed great trust in the staff at the home, and felt confident leaving their relation at night knowing they would be well looked after.
People received a well-balanced and nutritious diet. Meals were home cooked and people told us they were tasty. Where people were at risk of poor nutrition the home had taken action to monitor their intake refer them to other agencies such as the GP or dieticians for support.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People‘s rights regarding capacity and consent were understood and supported.
People’s privacy and dignity was respected, and their independence was encouraged as far as people were able. This included recognition of activities people could do for themselves, including eating and moving, although this might take additional time. The home had policies that enabled relatives to continue to be involved with their relations care, including personal care if they wished. This was a comfort to people, especially at the end of their lives.
Relatives told us they were involved in making and supporting decisions about people’s care where they were not able to do so, and we saw people received individual care in accordance with their agreed care plan.
The home had a very full activities programme, offering a wide variety of opportunities to meet people’s needs and wishes. These included opportunities to develop new skills such as using computers or Tai chi.
Records were well maintained, and appropriate notifications had been made to the Care Quality Commission as required by law.
Further information is in the detailed findings below.
This inspection took place on the 13 and 16 January 2015, and was unannounced. The second visit made to complete the inspection on 16 January 2015 was by appointment.
Bramble Down is a care home with nursing, situated in the village of Denbury, approximately three miles from the market town of Newton Abbot. The home is registered to provide nursing care for up to 40 people, and was full at the time of our inspection. People who lived at the home were older people with general nursing needs. Some people had moved to the home for end of life care, while others were there for a period of recovery and rehabilitation before returning to their own home.
As a policy the home does not provide care for people with dementia as a primary diagnosis, although we saw some people who lived there had a mild degree of memory loss associated with other ill health.
On our last inspection of the home in February 2014 we had identified concerns in relation to the staff recruitment processes in place and the staff’s understanding and recording of people’s capacity to consent to their care. The provider sent us an action plan telling us that they would complete improvements to put these right by the 30th April 2014. On this inspection we saw that the improvements needed had been made and sustained.
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 saw that people were supported in a service that was safe. Risks to people’s health and safety were managed appropriately and people had opportunities to remain independent and take appropriate risks to enhance their quality of life. Staff understood people’s rights and how to protect them from potential abuse or harm.
We saw that fluid balance charts had not always been fully completed where people were at risk of poor hydration. This meant that it was not possible for nurses to accurately check how much fluid people had taken. This put people at potential risk of poor hydration, although we did not identify anyone who was poorly hydrated on the inspection.
There were enough staff on duty throughout the day and night to meet people’s needs. People we spoke with told us their needs were met, and we saw that although the home was busy people received individualised care in the way they wanted.
People were asked about how they wanted their care to be delivered, and we saw that care was delivered in accordance with people’s care plans and their wishes. Care staff were well organised so that it was clear each day who they were responsible for supporting. This helped to ensure that people’s care needs did not get missed.
We saw that staff had the skills, knowledge and training to help them meet people’s needs. Staff told us they received good support at the home and that it was a good place to work.
We saw that the home managed people’s medication well, including complex pain relief for end of life care. The home’s staff were proactive in supporting people’s healthcare, and account was taken of people’s recovery goals and aspirations wherever possible. We saw that people had access to good community healthcare support services such as community physiotherapy or end of life care nurses.
People told us they enjoyed the meals at the home, which were described as good wholesome cooking, using fresh and local produce wherever possible. We saw people who needed support to eat were given this sensitively and in ways that respected their dignity.
People’s capacity to consent to care was recorded, and where they could not do this records and assessments showed that decisions had been made in people’s best interests. People's communication needs were assessed. We saw that no-one who lived at the home was being deprived of their liberty.
We saw that the staff were caring, both helping people to celebrate positive events and offer support at times of distress. We saw that there were good relationships between people receiving care and those supporting them. Staff we spoke with told us they were proud of the home’s approach to end of life care which was based on good practice and positive links with local hospice services.
People had access to interesting activities that met their needs and wishes. We saw that the activities organiser had used innovative, creative and individual approaches to supporting people to remain active and involved where they were able to be.
We saw that care was individual and person centred. Staff we spoke with had a good understanding of the backgrounds, needs and wishes of the people they were caring for. They understood the importance of social, emotional and spiritual elements of people’s care as well as medical needs.
The service managed any complaints or concerns well. People told us they felt able to raise any issues and be confident of a resolution without recrimination. The culture at Bramble Down was open and the manager told us her door “is always open”.
We saw that the provider met legal obligations to the Care Quality Commission, and was operating in accordance with their conditions of registration. Quality assurance and audit systems in place ensured that people received a consistently good standard of service, and that learning took place to develop the service further.
Care and treatment was delivered in a way that was intended to ensure people's safety and welfare. There was no evidence to confirm that people were asked for their consent or how the provider acted in accordance with their wishes before they received any care or treatment.
People who live at the home told us they were well looked after and were happy. One person said "I am very happy here. I am really well looked after'. A family member told us 'We were looking for a home where staff had compassion, and we have found it'.
People had been protected from unsafe or unsuitable equipment. This was because the provider had systems to ensure care staff were trained to use it and that regular servicing was carried out.
Records we looked at did not confirm that the provider gave serious consideration to recruitment decisions. We did not see that there was a robust recruitment procedure in place at Bramble Down to ensure suitable and properly qualified people had been employed by the home.
The provider had an effective system to regularly assess and monitor the quality of service that people received.
They told us 'the food is always well cooked and nicely presented', 'I only like to eat fish and I am served different fish meals every day', 'we can have our meals served in the dining room or my bedroom' and 'we always get fresh vegetables and home cooked meals'.
We found the home to be clean and tidy throughout and the management of medicines was generally all in order. If people wanted to make comments, raise concerns or complaints, that they would be listened to and appropriate action taken where possible.
We looked at the arrangements in place to support the staff team to do their jobs and found that staff were well trained and their work practice was supervised.
We spoke to one person during our visit about the reason for their admission and the care provided to them. They told us that they understood both why they were living at the home and about the care they were receiving.
People told us that their privacy and dignity were respected and that they were encouraged to express preferences and choices about their care and treatment.
We spoke to seven people during our visit, some of whom were living at the home and others who were visiting. People we spoke to were generally complimentary about the service provided by the care home and told us 'we are all cared for very well', 'Staff are so kind and look after us all' and 'I wouldn't want to be anywhere else, it's lovely here'.
One person told us that the staff were friendly and caring and that they brought drinks and food to them regularly. Another person, who chose to mostly stay in their room, told us they saw staff regularly.
A relative told us that staff keep them informed of any changes in their relative's health and involved them in planning how they were going to deliver care. They also said 'This is a lovely little place. The girls are lovely and look after me as well. It's nice to think you're appreciated'.
The four members of staff we spoke with had a good knowledge of people's needs and told us how the service was meeting these needs.
On the day of our visit we found that the care home was clean and people confirmed to us that this was always the case. A relative also confirmed this and told us 'if it wasn't I would let them know'.