Sursum Limited Bramley House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had developed a new statement of purpose and values statement, which had been displayed in the home. However, staff we spoke with were not aware of these values. The manager told us they would discuss these as part of staff meetings and supervision, to ensure all staff understood and worked in line with them.

Leaders did not always have the skills, knowledge and experience to lead effectively, or they did not always do so with integrity, openness and honesty. The service had experienced instability in the management team, with 3 managers over the previous 6 months. Two of these managers had been removed by the provider as they had not demonstrated they had the skills to fulfil their role effectively. Staff told us they felt the current manager was starting to make improvements, with 1 staff member commenting, “They are teaching us things and making us aware of things we thought were right but actually aren’t”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The manager told us the service had speaking up procedures, which staff could use if they needed to. Details were shared with staff during their induction and team meetings. Information on how to raise concerns was displayed on noticeboards in the service. Staff told us they knew how to raise concerns, and were confident the new manager would listen to them and respond.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people and staff. The manager told us they would support staff to make reasonable adjustments to their working patterns where needed, to support them to remain at work. Staff told us they felt they were treated fairly by the management team.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Some audits and checks of the service had been completed, but action had not been taken in a timely way to address identified shortfalls. For example, a medication audit had been completed on 16 December 2024 and identified that people did not have guidance in place for the use of ‘as required’ medicines. This action had not been completed and we found the guidance was not in place during this assessment. Water outlets assessed to be ‘unsatisfactory’ in a legionella risk assessment took 20 months to be rectified. The same fault with the emergency lighting system had been recorded each month for a year. Faults with fire doors had been repeatedly recorded over a 6 month period. This demonstrated systems to ensure management oversight of the service were not effective and had not resulted in shortfalls being addressed promptly. This increased the risk of people using the service and others being harmed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider told us they worked with a range of other professionals to help make sure people received continuity in their care. People told us the service worked in partnership with other agencies, including community and specialist nursing services.

The provider had started work to identify the extent of the shortfalls in the service and plan improvements. The provider had worked with an external specialist to complete a mock inspection of the service and develop plans to make the improvements needed. Information and training had been planned with staff to ensure everyone was aware of the improvements needed.