Archived: Bramley Court

People’s experience of using this service:

The feedback we received from people and relatives was good. Staff we met and spoke with were happy and proud; they were loyal and committed to the provider and registered manager. This was reflected in their attitudes and integrity during the inspection. All staff on duty were happy to contribute to the inspection and share their views and experiences.

The service was safe and risks to people were managed well. Staff knew how to protect people from harm and had received safeguarding training. People were living in a safe, well maintained environment. The service was clean and tidy and free from any unpleasant odour. There were enough staff employed to help keep people safe and to meet their needs. We found that recruitment practices were safe and the relevant checks were completed before staff started work at the service. There were systems in place to ensure medicines were managed, stored and administered safely.

The service was effective in meeting people’s needs. Staff received regular supervision and support. The annual training programme was extensive and equipped staff with essential skills and knowledge. Arrangements were made for people to see a GP and other healthcare professionals when they needed to do so. 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 were provided with a healthy, balanced diet whilst promoting and respecting choice.

The service was caring towards people. People were treated with kindness, respect and compassion and people were given support when they needed it. Staff were seen to be caring towards people they supported and spoke about people positively. Staff had very good knowledge of the people they supported, including their life histories, the things they liked and didn't like and the people who were important to them.

The service was responsive to people’s health and social needs. People received person-centred care and support. Regular monitoring and reviews meant that referrals had been made to appropriate health and social care professionals. Where necessary care and support had been changed to accurately reflect people's needs and improve their health and wellbeing. People received end of life care that was dignified, respectful and caring. People were encouraged to make their views known and the service responded by making changes.

The service was well led. People received a high standard of care because the management team led by example and had high expectations about the standards of care people should receive. Staff were enthusiastic and happy in their work. They felt supported within their roles and held the management team in high regard. Staff described working together as a team, how they were dedicated to providing person-centred care and helping people to achieve their potential. Systems were in place to monitor the quality and safety of the service and the care people received.

Rating at last inspection: Good (published October 2016).

Why we inspected: This was a planned inspection based on previous rating.

Follow up: We will continue to monitor the service through the information we receive. We will visit the service in line with our inspection schedule, or sooner if required.

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

Bramley Court is a care home with nursing for up to 76 people, some of whom are living with dementia. At the time of our inspection 75 people were using the service.

There was a registered manager in place who was present during 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that they felt safe in this home. Staff were aware of the need to keep people safe and they knew how to report allegations or suspicions of poor practice.

People received their medicines as prescribed. Medication was suitably stored and administered. Staff knew how to dispense medication safely and there were regular checks to make sure this had been done properly.

People were supported by staff who had the appropriate skills and knowledge they needed to meet their care needs. Staff received regular training and updates to maintain their knowledge of good practice and people’s latest care needs.

Meals times were promoted as a sociable and pleasant experience. People were kept safe from malnutrition because they were offered a choice of foods and drinks they liked. Staff knew how to support people to eat and drink enough to keep them well.

People were supported to have their mental and physical healthcare needs met. The registered manager sought and took advice from relevant health professionals when needed.

People said staff were caring and had built up close relationships with the members of staff who supported them. People and, where appropriate, their relatives were consulted about their preferences and people were treated with dignity and respect.

There was a wide range of activities for people to take part in which reflected their individual interests. People’s relatives and friends were made welcome and staff knew how to support people to pursue their cultural heritage and religious beliefs.

People had access to a complaints system and the registered manager responded appropriately to concerns. Where possible action had been taken to prevent similar issues from reoccurring.

There was effective leadership from the registered manager and senior members of staff to ensure that staff in all roles were well motivated and enthusiastic. The registered manager assessed and monitored the quality of care consistently through observation and regular audits of events and practice.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them, relatives and health and social care professionals and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that the support people received was safe. People reported positive improvements in the home, the comments made included: "I am happy with the care the staff give,' "I think it is getting better, we have more activities" and "Yes I think the home is safe." A relative said: 'We have weekly updates and they will contact us if they are concerned," Two health professionals and a commissioner of services also told us that the service had improved, but they expressed concerns that this improvement would be sustained.

We checked people's care plans and risk management plans and found these were detailed and up to date. Health risks were monitored and checked by the manager of the service.

We observed that generally there were enough staff to provide for people's care safely and when there were staff shortages the provider made arrangements for replacement staff to be brought on duty.

People's best interests had been managed appropriately under the Mental Capacity Act (2005). The manager was planning appropriately for any further best interest assessments. The home had policies and procedures in relation to Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

People were supported to have their nutritional and hydration needs met. People's weights were monitored and referrals were made to health professionals if needed.

There had been an increased focus on meeting the individual social care needs of people living in the home. Some people had individual time with activity coordinators and some people had been taken out for an external activity. There had been a very recent recruitment of third activity coordinator so the number of activities could be expanded. The environment had been improved to provide more interest and stimulations to people who walk around the home and items were available for them to pick up and look at.

There was suitable equipment to support staff in meeting people's needs. The equipment was regularly serviced and systems were in place to check that it remained fit for use in between servicing.

Is the service caring?

During our observations we saw that people were supported by care staff who explained to people how they were going to be supported before they were assisted. We saw that there was increasing move to provide for people's preferences as well as their needs. Amongst the comments we received were: 'We are happy our relative is here they are really great with her' and 'There has been a great improvement in (the person's name) care.'

Interactions between staff and people who used the service was observed to be kind and appropriate. There was evidence that some people were getting individual quality time with activity coordinators.

Is the service responsive?

Concerns or complaints were investigated and responses given to people. Where incidents of concern arose between residents these were appropriately notified to us and the local safeguarding authority.

Health professionals told us that the service had improved in referring people who had issues with their skin at an early stage and were responding to their recommendations.

A commissioner of services told us that the service had improved and an action plan that had been in place to address concerns about records and care had been met.

Is the service well-led?

At the time of this inspection the manager was awaiting an interview to be registered with us.

Systems were in place to monitor the quality of service the home provided and to minimise risks of harm to people so that people were safe and well cared for.

We saw that there were systems in place to monitor a range of aspects of the home. For example: the safety of the home environment, equipment, medication storage and procedures, pressure area care and weights of people living in the home. The manager had introduced and undertaken a three monthly audit of all services and had reported on the quality of the service being provided.

We had received information of concern following our inspection visit about the conduct and skills of some staff who worked in the home in March 2014. We raised the concerns with the manager and established that in response to concerns they had identified at that time the manager had initiated spot checks on staff working during evenings and nights and had introduced and enforced clear expectations the provider had of staff conduct whilst on duty.

As the majority of people in the home were unable to tell us about their care we spoke with seven relatives and staff from the local authority. We observed the interactions between staff and people who lived in the home. Relatives, we spoke with, told us that they thought their relative was safe in the home and that the care staff were caring but busy. Our observations at meal times and during our SOFI observations indicated that people had brief interactions with staff when they needed some support with personal care tasks, but there were greater spans of time when interactions between staff and people living at the home were infrequent. There was no consistent effective programme of activities or entertainment provided for people living in the home. We observed that people spent their time being neither happy nor sad and at times appropriate support for people was not given to meet their needs.

Care plans did not support the care people received. The relatives we spoke with who acted on behalf of people who lived in the home had not always seen care plans when they had been written or updated. Whilst relatives thought they could raise concerns easily with staff members they were unsure that 'the message got passed on' and were not always sure of the designation or role of the staff member they spoke with. Records indicated that complaints were not always responded to effectively.

We could not find appropriate systems were in place to ensure that people received consistent care. Since our last inspection another manager had left the home. The service has had six managers since June 2012 and there has been significant turnover of qualified nurses. Systems used by the provider have not been robust enough to ensure that the service was well-led.

At the time of our inspection the provider did not have a registered manager in post.

On 2 October we found improvements had been made on the administration of medicines and record keeping. The administration, and storage of medicines were safe and records were accessible and fit for purpose. We found that was enough staff employed to appropriate care and staff were generally given the training they needed to assist people appropriately. The expert by experience spoke with four people and three relatives and an inspector spoke with another relative. People told us they felt safe and cared for amongst their comments were: "It is great in here and the staff are lovely," and "Staff are very nice and I like living here, they are kind and helpful." Two relatives told us the home was improving.

We spoke with eleven staff, looked at care records, observed care and took account of information that we had received before our visit and found that people received inconsistent care. Although appropriate information was collected before people were admitted into the home this did not always mean that people had a good experience when they first arrived. At times there had been a lack of appropriate communication between staff and lines of reporting and responsibility were not clear enough. This resulted in an incident of paramedics being turned away from the home, a person's preferences not being adhered to, a health concern not being planned for and inconsistent quality in how people experience their care.

On 10 October 2013 we visited Bramley Grove on the same day as concerns were raised with us about the home and hot water being cold. The manager had already told us following our first visit about the failure of the home's central heating and hot water boiler. They kept us informed of arrangements they had made in this emergency to keep people safe; the temporary repair to the system and the planned replacement of boilers. On this visit the home was warm enough and the hot water supply was not cold although it was clear some efficiency had been lost and it was running cooler than usually expected.

Following our visit on 22 October 2012 concerns were raised with us about the care and safety of people living in the home. None of the concerns named specific people, dates or times of incidents for us to be able to track specific events. However, during our visits on 28 and 30 November and 3 December 2012 we identified poor outcomes for people's: nutrition, hydration and skin care, medicine administration and when people were assisted to move. Staff behaviour throughout the organisation and records needed to improve.

We continued to visit the home to check the well being of people. On this visit we found improvements in the identification, action taken and recording of when people's health conditions deteriorated. We also found that care staff were more organised and confident about the care they were providing. Although there remained some risks of poor outcomes for people about: medicine administration, records and development of plans of care that reflected people's individuality these concerns were substantially less than previously.

We visited Bramley Court to undertake a themed inspection in June 2012 which looked at how people's dignity and nutrition needs were met. We had serious concerns and issued a warning notice about nutrition. We visited in October 2012 to follow up these concerns. Our observations, contact with the commissioners of the service and conversations with people who lived in the home and relatives indicated that the home was improving.

Following our visit on 22 October 2012 concerns were raised with us about the care and safety of people living in the home. None of the concerns named specific people, dates or times of incidents for us to be able to track specific events. However, during our visits on 28 and 30 November and 3 December 2012 we identified poor outcomes for people's: nutrition, hydration and skin care, medicine administration and when people were assisted to move. Staff behaviour throughout the organisation and records needed to improve.

We have continued to visit to check the well being of people and our concerns remain. Where areas of non compliance have been identified during inspections they are being followed up and we will report on any action when it is complete.

We visited Bramley Court to undertake a themed inspection in June 2012 which looked at how people's dignity and nutrition needs were met. We had serious concerns and issued a warning notice about nutrition. We visited in October 2012 to follow up these concerns. Our observations, contact with the commissioners of the service and conversations with people who lived in the home and relatives indicated that the home was improving.

Following our visit on 22 October 2012 concerns were raised with us about the care and safety of people living in the home. None of the concerns named specific people, dates or times of incidents for us to be able to track specific events. However, during our visits on 28 and 30 November and 3 December 2012 we identified poor outcomes for people's: nutrition, hydration and skin care, medicine administration and when people were assisted to move. Staff behaviour throughout the organisation and records needed to improve.

We visited twice in December 2012 and twice in January 2013 to check the well being of people and our concerns remain. Where areas of non compliance have been identified during inspections they are being followed up and we will report on any action when it is complete.

We visited Bramley Court to undertake a themed inspection in June 2012 which looked at how people's dignity and nutrition needs were met. We had serious concerns and issued a warning notice about nutrition. We visited on 22 October 2012 to follow up these concerns. Our observations, contact with the commissioners of the service and conversations with people that lived in the home and relatives indicated that the home was improving.

Following our visit on 22 October 2012 concerns were raised with us about the care and safety of people living in the home. None of the concerns named specific people, dates or times of incidents for us to be able to track specific events. However, there were themes and we looked at during our visits on 28 and 30 November and 3 December 2012. The concerns were about: people's nutrition, hydration and skin care, medicine administration, equipment and moving people, staff attitudes and behaviour throughout the organisation and records.

We visited on 12 and 27 December 2012 to check the well being of people and our concerns remain. Where areas of non compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

Following our visit on 22 October 2012 concerns were raised with us about the care and safety of people living in the home. None of the concerns raised named specific people, dates or times of incidents for us to be able to track specific events. However, there were some consistent themes of concern that we looked at during our visits on 28 and 30 November and 3 December 2012. These concerns were about the moving and handling of people, people's nutrition and hydration, skin care, medicine administration, equipment, staff attitudes and behaviour throughout the organisation and records.

We looked at all these areas of concern in detail and found that improvements had not been sustained. In addition we had concerns about compliance in other outcome areas that we had not looked at during our previous inspections.

Where areas of non compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

Visitors in one lounge commented on the increased availability of drinks every time they visited, remarking, "My relative always has at least one cold drink within easy reach every time we visit, and this is not like it used to be."

Visitors advised that they had no concerns about the care of their relatives and friends. Some were able to be closely involved in supporting the person living in the home, and positive comments were received about recent changes in the home and increased staffing that was summarised by one person who said that, 'Changes have made a difference as the home is a calmer with more predictable timings of daily routines, and more staff present in the main areas of the home.'