Bramhall Manor Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the safe management of medicines.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learned to continually identify and embed good practice.

Systems in place for oversight and learning had not always been effective in ensuring learning was embedded. For example, we found a number of concerns in relation to the management of medicines which had been raised with the provider at our previous inspection. These included the management of topical creams and thickening powders and adherence to manufacturer guidance regarding the administration of medicines.

We found improvements in the oversight of staff responses to call bells, with monthly reports and investigations undertaken where there had been delays in responses. Whilst the average response time to call bells was generally good, there were occasions when people were left waiting for significant periods of time, particularly during busy times of the day and when staffing levels were reduced at night. One person raised delays in responses as a concern, and a relative commented, “It’s not very nice for [family member] needing to wait if they have had an accident..” The registered manager told us they reviewed staffing dependency levels regularly and made adjustments when shortfalls were identified. This included consideration of dependency levels within each unit to ensure that the demands on staff could be effectively managed.

We found our previous concerns in relation to the implementation of risk assessments and care plans for people newly admitted to the service had been addressed. However, we found some people’s risk assessments had not been fully completed, despite being reviewed by staff regularly. The registered manager assured us that action had been taken to address this matter following our visit.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was effectively managed and monitored. They ensured continuity of care, including when people moved between different services.

The provider made appropriate referrals to partner agencies when areas of need were identified. The registered manager reported excellent working relationships with the local GP surgery and other external professionals, including dietitians, speech and language therapists, and a chiropodist. Guidance provided by external professionals was generally reflected and incorporated within people’s care records.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best ways to achieve this. Staff focused on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider shared concerns quickly and appropriately.

People and families gave positive feedback about the service and reported they received the care and support they needed and felt safe. We observed positive outcomes for people who were supported to develop friendships within the home and to access the local community and outdoor spaces.

Where safeguarding concerns were raised, these were appropriately investigated by the provider and shared with relevant external partners. Suitable policies and training were in place, and staff demonstrated a clear understanding of their responsibilities in safeguarding people.

Where people lacked capacity, appropriate, decision‑specific mental capacity assessments and best‑interest decisions had been completed. Where people were subject to restrictions, appropriate Deprivation of Liberty Safeguards (DoLS) referrals had been made.

The provider did not always work effectively with people to understand and manage risks. Staff did not always provide care in a way that met people’s needs safely, was supportive, or enabled people to do the things that mattered to them.

People’s needs and risks were assessed; however, we found occasions where the information recorded within these assessments was not accurate. This meant the extent of the risk may not have been fully identified, and this lack of clarity had not been addressed through regular reviews of people’s needs. We discussed shortfalls in relation to the management of choking risks, particularly for people prescribed modified fluids with the registered manager. The registered manager was responsive to these concerns and implemented a new risk assessment, which included more detailed information about choking risks for everyone living at the home by the second day of the inspection.

Flash meetings were used to provide oversight of people at risk, including in relation to fluid intake due to infection. However, these did not include everyone identified as being on fluid monitoring within the electronic care planning system or those at higher risk of infection, such as people with a catheter who benefit from good oral fluid intake due to their increased risk of developing infections. Records relating to fluid input and output for people with a catheter were not always consistently completed or monitored.

Risk management relating to falls had improved, with care plans and risk assessments being updated following any fall. The registered manager encouraged staff to focus on how further falls could be prevented. The provider also had a physiotherapy team working with people, both in groups and individually, to improve mobility and reduce the risk of falls. This had resulted in positive outcomes for people, including increased mobility and independence. The provider had also introduced a monitoring system, with consent, in people’s bedrooms to alert staff when people began to move, enabling earlier intervention to help prevent falls. The system also provided information about how a fall had occurred, which supported the implementation of preventative measures. One person commented, “Twice I have had a fall. I needed to go to AE but nothing was broken. Once I fell onto my bed; the next time I came out of the bathroom, and I was carrying too many things. A risk assessment was done, and my bed was lowered and a mat was put by the side.”

People’s skin integrity was generally managed appropriately, with regular repositioning and management of any wounds. However, records did not always demonstrate that care was being delivered in line with the needs identified in care plans. We found some improvements in the application of topical creams to promote healthy skin; however, there were shortfalls in the recording of cream application for some people. We also found risks relating to the accessibility of creams had not been fully assessed. Creams were accessible within people’s bathrooms throughout the home, which may pose a risk, particularly for people living with dementia. The registered manager confirmed that action had been taken to introduce lockable storage in some units. We will review the effectiveness and consistency of these measures across the service at our next inspection

The provider did not always identify and manage potential risks within the care environment. They did not consistently ensure that equipment, facilities, and technology supported the delivery of safe care.

The home provided specialist support to people living with dementia; however, further work was required to ensure the environment fully met people’s needs. This included consideration of dementia‑friendly signage and the use of contrasting colours to ensure equipment, such as handrails, was clearly visible and accessible for people whose visual perceptions had deteriorated.

Regular checks and maintenance of equipment were carried out, and any issues identified were promptly addressed by the maintenance staff. People had access to outdoor spaces which were safe and secure, and individuals were supported to personalise their bedrooms.

Cleaning equipment and thickening powders were suitably secured; however, the risks associated with people having access to topical creams had not been fully considered or addressed by the provider at the time of our visit. This was actioned by the registered manager following our visit and locked boxes were implemented to ensure secure storage.

The provider did not always ensure there were sufficient numbers of qualified, skilled, and experienced staff. They did not consistently ensure staff received effective support, supervision, and development.

We received mixed feedback about staffing levels, which was the main area of shortfall identified through surveys and meetings with people and their relatives. Call bell records indicated staff generally responded promptly; however, we identified occasions when there were significant delays. One family had raised this as a complaint with the registered manager, who was investigating the matter at the time of our inspection. One person told us, “Staff can be busy; I have a care pendant if I need help.” Another person said, “I press the buzzer and it takes a long time for them to come.”

The registered manager told us they reviewed staffing dependency levels regularly and made adjustments when shortfalls were identified. This included consideration of dependency levels within each unit to ensure that the demands on staff could be effectively managed.

Feedback from staff was staffing levels were generally sufficient. On the day of our visit, we observed staff attending promptly to people’s needs and supporting people with kindness and patience.

The provider’s recruitment policy was followed when recruiting new staff. Staff completed an induction before working directly with people and undertook a range of training. Since our last inspection, there was evidence regular supervision sessions were being completed. Staff told us they felt they had the training they needed to carry out their roles and felt well supported. People generally felt staff were competent and understood their needs, with one person stating, “Staff hoist me into bed; they know what they are doing.”

However, we identified some gaps in training for a small number of staff. The registered manager advised us this was being addressed. We also found not all new starters had completed training specific to supporting people with a learning disability and autistic people. The provider explained this training had been booked; however, there had been challenges in securing external training providers due to high demand. We discussed how staff might benefit from additional training around specific conditions and how these affect individuals, for example, those living with Parkinson’s disease or those requiring specific equipment such as a catheter or stoma, with the registered manager.

The provider assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared any concerns promptly with appropriate external agencies.

The home was clean and tidy, and domestic staff worked throughout the units completing both routine surface cleaning and scheduled deep cleans across the home. Infection prevention and control audits indicated good practice was embedded. Staff had completed appropriate training in infection prevention and control, and hand‑washing competency checks had been undertaken. We observed staff using personal protective equipment appropriately.

People were supported to access baths and showers; however, records did not always evidence personal care was provided in line with people’s stated preferences or at regular intervals. Records relating to the support people received with oral care were well maintained for most people. People were supported to access dental care, either through visits from a dentist to the home or by attending appointments with their own dentist.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines, including medicines with additional storage requirements, were stored safely. The remaining quantities of medicines showed they had been administered as prescribed. However, medicines to be given at specific times were not always given at the correct times. This meant people might experience symptoms of the condition the medicine was prescribed to treat. We also found one person was not having their medicine in line with the manufacturer’s directions, which meant it might not work properly.

We found ‘when required’ medicines had person centred information available to support staff to know when to give the medicines. However, we saw one person was prescribed two laxatives, with no information available to support staff to know when to give one medicine in preference to the other.

Risk assessments were completed for people; however, they did not always identify all of the risks and were not always completed correctly. For example, 2 peoples ‘falls’ risk assessments had questions answered incorrectly, therefore the risks had not been fully identified and assessed.

One medicine administration record reviewed showed a medicine for one person had been temporarily stopped whilst the doctor completed a review, however the staff we spoke with were not aware the medicine had been reviewed. Following a discussion with the staff they contacted the doctor who re-started the medicine.

Audits were completed; however, they had not identified all of the issues found during the inspection. Staff told us they completed medicines related training and had their competency assessed; we saw evidence to confirm this.