Bramhall Manor Care Home

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 service 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 requires improvement. At this assessment the rating has remained 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 service was in breach of legal regulation in relation to governance at the service.

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 not effectively ensured a shared direction and strategy where staff understood their role in achieving the provider visions. For example, the provider had developed various strategies to address concerns noted at previous inspections but these strategic goals and compliance with regulations had not yet been achieved. The provider recognised the challenges for staff managing the care for people admitted to the home for short term placements and had taken steps to reduce the number of beds for this type of care. However, whilst there remained several people on short term placements, the continuing challenges resulted in shortfalls in some areas of care for both these people as well as those living at the home permanently. The provider’s vision in these areas had not yet been realised. Some shortfalls in care delivery including the management of people’s safety and record keeping indicated that further work was needed to ensure safe and quality care was being consistently delivered.

People, families and staff generally spoke positively about the quality and safety of the service.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the knowledge and experience and credibility to lead effectively.

Whilst there was a clear management structure and processes in place this had not always led to the improvements needed being implemented and embedded in practice. The provider’s systems for governance had identified areas of shortfall, such as around record keeping but had not taken steps to understand the reasons for this issue continuing to reoccur and ensure it was effectively addressed. People spoke positively about the registered manager who they felt was approachable and staff felt supported by the service’s management team.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Systems were in place for people, families and staff to feedback about the service and raise concerns. People and families commented that they felt able to raise any issues and were confident that these would be addressed. Staff did not raise that they had any concerns about sharing issues or concerns with the provider.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us they supported staff with a variety of different needs which included some flexibility in work patterns based on people’s cultural and spiritual needs. The provider ran an initiative called ‘wellbeing Wednesday’ where there was a focus on mental wellbeing. The provider had several other initiatives and rewards for employees. Staff generally told us they felt well supported. The registered manager told us they had an open door policy and wanted to encourage and support staff to learn and foster and open learning culture.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had introduced a range of checks and audits which were being completed on a regular basis. However, these had not been sufficient to resolve issues found at our last inspection in relation to records of diet and fluid and repositioning. Further work was needed to ensure these were effective in identifying and addressing shortfalls and ensuring accurate and contemporaneous records were being maintained. We also noted other areas of shortfall in including in relation to medicines and recruitment which had not been identified by the provider.

We noted occasions where the provider was not following their own policies. For example, in relation to recruitment, their policy stated they required satisfactory evidence of conduct including for all previous roles which related to health and social care, including children or vulnerable adults, and was not time limited but we found examples where there was no evidence these references were being sought. We found the supervision policy stated a current supervision frequency of 6 per year which should be documented in the annual planner, but the planner indicated that some staff who had been there for 12 months had only received between 3 and 5 supervisions during the 12-month cycle. Whilst we found no evidence of impact for people using the service, the failure to address areas of risk and record keeping and follow policies to ensure the safety of the service placed people at potential risk of harm.

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.

People were receiving care which involved relevant partner agencies. The provider appeared to have good working relations with local services and the activity coordinator was working to develop further relationships within the community including local schools. The provider had links with religious organisations who provided spiritual support where people wished. People engaged in external activities including trips out and one person regularly attended a day centre.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

A range of systems were in place to learn lessons. However, it was not always clear that where areas of shortfall were identified, that these had been effectively addressed. There was limited assurance that areas of improvement were being consistently addressed with the staff team to identify the root cause of shortfalls in record keeping for example.