Bramblings Residential Home

Bramblings Residential Home is a care home accommodating up to 42 people in one building. The service had an old wing and a new wing and was arranged across two floors with lift access. At the time of our inspection there were 29 people living in the service. People had a variety of care needs including Parkinson’s disease, epilepsy and people living with dementia. Very few people were able to walk around the service independently.

People’s experience of using this service and what we found

People told us they felt safe and were happy living in Bramblings. One person said, “I am very well looked after. I choose to stay in my room.” Relatives agreed people were safe and happy. One relative said, “We are very happy with it. Kindness and care are most important to us and that is what they get.” Another relative said of the management team, “They have done a fantastic job of bringing this care home to life, and making it a secure, safe place for the people.”

People received safe care and treatment from staff who knew them well. Medicines were managed safely, and lessons were learned when things went wrong. Enough staff were deployed to meet peoples’ needs.

People enjoyed the food and their dietary needs and preferences were met, for example gluten free. People had choices and could ask if they wanted something not on the menu. Cold and hot drinks were offered to people throughout the day.

Quality assurance processes were in place to monitor the service and regular audits were undertaken. Staff had received appropriate training. Staff told us they found the registered manager approachable and supportive.

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.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 July 2019) and there were breaches of regulation. The provider completed an action plan after the 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 regulations. However, there were areas in need of improvement identified at this inspection.

Why we inspected

We received concerns in relation to staffing levels, training and incident reporting. As a result, we undertook a focused inspection to review the key questions of safe, effective and well led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance the service can respond to COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection people were at risk of harm from the concerns raised. Please see the safe and effective sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bramblings Residential Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Bramblings Residential Home is a residential care home accommodating up to 42 older people in one adapted building. There were 31 people living at the service at the time of our inspection. People had varying care needs, including, living with dementia, Parkinson’s disease, epilepsy and diabetes. Some people could walk around independently, and other people needed the assistance of staff or staff and equipment to help them to move around.

People’s experience of using this service and what we found

Although improvements had been made in most areas and this was continuing, some areas continued to need further work to ensure a good service was received.

Environmental risks were present as doors to areas that housed equipment or substances that could be harmful to people were left unlocked, posing a potential hazard to people’s safety. Individual risks to people’s health and safety had improved, however, some areas of risk had not been identified so measures were not in place to protect people.

The safe management of people’s prescribed medicines had improved, people were given their medicines by staff who had received additional training to ensure their competence. There were still areas of concern that meant further safety measures needed to be applied around topical creams, patches and the safe disposal of medicines.

Some staff had not kept their essential training up to date and new staff had not completed training deemed mandatory by the provider in a timely manner to make sure they had the skills to provide the care people needed.

The premises needed updating and repairs were not always carried out quickly, creating potential health and safety risks. Areas of the service and the signs in place did not present a dementia friendly environment. The garden was not accessible for many people as it was overgrown at a time when the weather permitted opportunities for people to enjoy the outdoors.

People’s care records were not always accurately recorded to make sure their needs were fully met, although improvements had been made in this area. Improvements had been made to the monitoring and auditing processes to check the quality and safety of the service, however, this area needed to improve further. The quality processes needed to be embedded and sustained to provide assurance.

Access and opportunities to meaningful activities that met people’s social needs and preferences needed further improvement. We have made a recommendation about this.

Care plans to help staff support people with their wishes at the end of their life were still a work in progress and needed further improvement.

Improvements had been made to staffing levels. People told us they did not have to wait for staff to assist them and staff said they could spend more time with people, meaning their own well-being had improved. Safe recruitment practices continued to be used. Staff had a good understanding of how to keep people safe and what their responsibilities were to raise concerns they had about people’s treatment.

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.

People were supported to access the advice of healthcare professionals and treatment plans were now followed. Only good feedback was given about the food and people were given assistance when they needed it.

A more person-centred care planning process had been introduced and this was reflected in the staff approach to care and support. People were supported with their individual communication needs and this was evident when observing in the communal areas. Supporting people to maintain their independence was clear from care planning documents and seeing the support provided.

How complaints and concerns were listened to and dealt with was more open and the opportunity was taken to learn lessons from issues raised.

The manager had been appointed since the last inspection, after the previous registered manager had left. The staff we spoke with had overwhelmingly positive comments to make about the manager’s open approach and their willingness to listen to and support staff as well as people. We were told this had a positive impact on staff morale.

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

Rating at last inspection and update

The last rating for this service was inadequate (published on13 April 2019) and there were multiple breaches of regulation. We took enforcement action against the provider. We imposed conditions on their registration to make sure they sent us a report each month to update on progress made towards improvements. The provider submitted a plan of action to show what they would do and by when to improve. At this inspection we found improvements had been made in many areas and the provider was no longer in breach of some regulations. However, improvements were continuing and the provider was still in breach of three regulations. More time was needed to make sure improvements could continue and be sustained.

This service has been in Special Measures since 13 April 2019. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified three breaches in relation to, safe care and treatment and medicines management; staff knowledge and skills; accurate record keeping and effective monitoring of the quality and safety of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Bramblings Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bramblings Residential Home provides accommodation and support for up to 42 older people. There were 36 people living at the service at the time of our inspection. People had varying care needs. Some people were living with dementia, some people had diabetes or had Parkinson’s disease, some people required support with their mobility around the home and others were able to walk around independently.

A registered manager was employed at the service. 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.

At our last inspection on 21 and 22 November 2017, the service was rated as ‘Requires Improvement’. We found breaches of Regulations 9, 11, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to, medicines administration processes were not managed safely; safe systems were not in place to identify and manage individual risks; robust recruitment processes were not used to make sure only suitable staff were employed; the basic principles of the Mental Capacity Act 2005 were not adhered to; effective system were not in operation to identify shortfalls in quality and safety; people’s needs and preferences were not met through the care planning and review system; Staff did not receive the appropriate training and supervision to carry out their role.

We took enforcement action against the provider and registered manager and told them they must meet Regulations 12 and 17 by 22 February 2018. At this inspection, improvements had been made to the management of people’s prescribed medicines, however the practices used when giving medicines to people were not safe. Risks to people’s safety were still not appropriately managed to prevent harm. Although accidents and incidents were suitably recorded, the management of falls continued to be a safety concern. Although some improvements had been made to quality monitoring, these were not robust enough to identify and sustain improvements.

The provider and registered manager sent an action plan dated 4 February 2018 stating they would meet Regulation 18 by May 2018 and Regulations 9, 11 and 19 by August 2018. At this inspection, the provider and registered manager had made improvements in some areas. Recruitment processes were now more robust, records showed safe practices were in place so only suitable staff were employed. Staff were now receiving the training and supervision support to carry out their role in providing care and support to people. However, the protection of people’s rights within the basic principles of the Mental Capacity Act 2005 continued to be an issue of concern. Time had been spent on a new care planning system, however, care plans did not capture and accurately record people’s specific and individual needs.

Although the provider and registered manager said they had enough staff to meet people’s needs, staff thought there were not enough to meet people’s social and emotional needs. Our observations showed this. We have made a recommendation about this.

Some people had their breakfast very late in the morning which meant they were not always able to eat their lunch, placing them at risk of not eating a healthy balanced diet. Their care plan did not record if it was their preference to get up late in the morning. This is an area we found needed improvement.

People’s end of life wishes had been recorded, however, some people’s care plans did not include the detail needed to make sure people’s wishes were known. This is an area that needed further improvement.

No complaints had been logged since the last inspection. When people and their relatives were speaking with us it was clear some concerns had been raised, and although dealt with to people’s satisfaction, there was no record of these to make sure lessons could be learnt. We have made a recommendation about this.

Improvements to fire safety measures had been made, including fire alarm testing and fire evacuation drills to keep people safe. All essential maintenance and servicing had been carried out at the appropriate times.

The service was clean and odour free and infection control practices were being used to better effect.

Staff knew their responsibilities in keeping people safe from abuse. Procedures were in place for staff to follow. The provider and registered manager had worked with the local safeguarding team when concerns had been raised.

The provider carried out an initial assessment with people before they moved in to the service and a care plan was developed. People were involved in the assessment, together with their relatives where appropriate.

People were happy with the food and confirmed they had a choice. People were supported to access some healthcare professionals such as GP’s when needed. However, some people had not been appropriately referred for appropriate advice and guidance as records had not been maintained and monitored.

People described staff as kind and caring. However, people were left for long periods of time without staff chatting with them or helping them to get involved in their interests. People’s dignity was not always respected.

Staff respected people’s privacy by knocking before entering their personal bedroom space. People confirmed they were encouraged to maintain their independence.

Activities coordinators helped people to access things to do through the day. There was scope for further improvements and this had been recognised by the provider who was taking action.

People and their relatives found the registered manager and deputy manager to be approachable and available to listen. They felt their views were heard and acted on.

Staff felt supported and confirmed they could speak with the registered manager at any time if they needed to.

The provider had displayed the ratings from the last inspection, in November 2017, in a prominent place so that people and their visitors were able to see them.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. You can see what action we told the provider to take at the back of the full version of this report.

Bramblings Residential Home is registered to provide accommodation and personal care without nursing for up to 42 people. There were 36 people living at the service at the time of our inspection.

People living in the service required care and support and had varying needs. Some people were living with dementia and some people had medical conditions such as diabetes or respiratory conditions and some people were recovering from suffering a stroke. Most people living in the service needed some support to move around. Some required the support of one staff member to move around whilst others required the support of two staff. Two people needed staff to support them to move by using a hoist. Some people were unwell and cared for in bed and others chose to remain in bed.

The service was set out over two floors with a passenger lift to take people between floors. The service was set in large grounds with pleasant gardens that people could sit out in when the weather was fine.

A registered manager was employed at the service. 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.

The last inspection report for Bramblings Residential Home was published on 13 December 2016 following a comprehensive inspection on 24 October 2016 when the service was rated requires improvement. Four breaches of legal requirements were found in relation to Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider and registered manager to take action to meet the regulations.

After the inspection, the provider sent us an action plan on 14 December 2016 which detailed how they planned to address the breaches of Regulations. They said they would be compliant by June 2017.

At this inspection, we found some improvements had been made to meet the regulations, however further improvement was required and the service continued to be in breach of regulations.

Some elements of how medicines administration was managed continued to need improvement. Prescribed thickeners to add to people’s drinks to prevent choking were not stored or administered safely. Anomalies were found in the numbers of medicines in stock when checked. Medicines audits did not highlight the concerns found.

Individual risk assessments were not in place to give the guidance necessary to staff when providing care to keep people safe and prevent harm. Infection control procedures were not robust as people shared the use of a hoist sling and personal toiletry products were left in communal bathrooms.

Fire prevention processes were not always evidenced to show robust systems were in place to keep people safe in the event of a fire on the premises. All servicing of systems and equipment had been carried out by the appropriate professionals.

Safe recruitment procedures were not followed to ensure only suitable staff were employed to provide care and support to people living in the service.

Staff did not always complete the training required to carry out their role. One to one staff supervision was not undertaken regularly or as described in the provider’s supervision procedure.

The basic principles of the Mental Capacity Act 2005 had not always been followed to ensure people’s rights were upheld. Deprivation of Liberty Safeguards applications had been made and the registered manager kept these under review.

People’s needs were not regularly assessed to ensure the appropriate care and support was being delivered. People’s needs had changed and care plan reviews did not capture this to make sure staff were given the most up to date information. People’s interests and preferences were not always identified and recorded.

The provider had a system in place to monitor the quality and safety of the service. However, these were not effective enough to identify the failings or improvements required.

People were referred to appropriate health care professionals when required although changes to care and treatment were not always reflected in care plans. We have made a recommendation about this.

Mealtimes were not always equally spaced out so that people could manage their appetite and nutritional intake. We have made a recommendation about this.

There were suitable numbers of staff to provide the care and support needed by the people living in the service. Staff had a good understanding of their responsibilities in safeguarding people from abuse and where they could report any concerns they had.

People were able to access all areas of the service whatever their mobility needs were.

Staff knew people well and spent time with people to make sure they were not rushed. People were supported to maintain their independence and they told us they were treated with dignity and respect.

People and their relatives knew how to complain. Complaints had been fully investigated and responded to as set out in the provider’s complaints procedure.

People were able to express their views of the service through regular meetings and annual surveys. The provider and registered manager made changes where necessary based on people’s feedback.

Positive feedback was given about the management team and how the service was run. Staff felt supported and listened to.

During this inspection we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. You can see what action we told the provider to take at the back of the full version of this report.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Staff were knowledgeable about the risks associated with people`s daily living and routinely mitigated some of these identified risks. However there were very few risk assessments developed with management plans to offer guidance for staff in what steps were needed to mitigate the risks.

People who had a diagnosis of dementia or had a confused state of mind had no mental capacity assessments in place to establish if they had capacity to understand and take informed decisions regarding the care and support they received from staff. Best interest processes were not followed to ensure the care and support people received was in their best interest.

Where people had restrictions applied to their freedom in order to keep them safe, the registered manager has not applied for Deprivation of Liberty Authorisations (DoLS) to ensure they were depriving people of their liberty lawfully.

People had their medicines administered by trained staff; however they did not always receive their medicines as intended by the prescriber. Staff failed to ensure that people had their medicines available in sufficient quantities.

People had little opportunities to participate in activities or pursue their hobbies and interest. When activity staff were absent there were no alternative arrangements in place to ensure people were provided with an activity programme of interest to occupy their time.

People told us they were involved in decisions about their care, however, some people could not recall having been involved and their consent was not always accurately reflected in their individual plans of care. Care plans were not personalised to reflect people`s likes, dislikes and preferences about the care they received. These had not identified and detailed all the care needs people had and did not offer sufficient guidance for staff to understand and deliver care and support in a personalised way. People`s care plans were not always reflective of their current needs.

People who lived at the home were positive about the skills and abilities of the care staff. Staff received induction training when they started working at the home and yearly refresher training in key areas such as safeguarding, infection control, manual handling and first aid. However the registered manager could not evidence to us that agency staff working at the home received any training or if they were suitable to work and deliver care to people. Staff told us they had regular supervisions and felt supported by the home management team.

The quality assurance systems were not effective. The regular audits carried out by the registered manager and the provider were not comprehensive enough and had not identified all the issues and concerns we identified at this inspection. Care records were not up to date and not always reflective of people`s care needs.

People were cared for in a kind and compassionate way by staff who knew them well and were familiar with their individual needs, preferences and personal circumstances. We saw that staff had developed positive and caring relationships with people who lived at the home. They provided care and support in a respectful way promoting people`s privacy and dignity.

There were sufficient numbers of suitable staff available to meet people’s needs consistently across all areas of the home. Safe and effective recruitment practices were followed to make sure that staff were of good character and had the experience and qualifications necessary for the roles they performed. Staff were knowledgeable about the risks of potential abuse and knew how to report any concerns they had internally and externally to local safeguarding authorities.

At this inspection we found the service to be in breach of Regulations 12, 11, 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of the report.

We found that the provider had taken action to address concerns around assessing and monitoring the quality of service that people received. We also found that appropriate action had been taken to ensure that people's care plans had been regularly reviewed in order to accurately reflect each individual's needs and that people's personal records were securely maintained.

Our observations on the day showed that people were supported by staff in a way that promoted their dignity and independence. The atmosphere in the home seemed relaxed and staff were observed to be caring and supportive in their approach to people. They appeared to know them well and clearly understood their needs and preferences.

We found that the provider had addressed our previous concerns regarding staff training and supervision. Staff told us that they were able to access the required training in order to deliver safe and appropriate care to people who lived in the home.

We found that the service had completed the appropriate checks in order to maintain a safe and suitable environment for people but improvement is required with regards to monitoring and reviewing the care provided.

We found concerns that people's personal records were not always updated in order to accurately reflect their care needs and that personal information was not securely stored.

People spoke highly of the staff and told us they were happy with the care provided at the home. Comments included "I like it here", "People are well looked after" and "The staff are lovely and come quickly when you call them".

We found that people were encouraged to be as independent as possible, were supported to make choices and be involved in their care. People said that staff are "Friendly" and "Attentive" and if they had any concerns they knew who to speak with.

All of the people we spoke with said they liked the food and were involved in menu choices. One person told us "I've just had a nice big dinner and now I've got pudding" and "If I don't like what's on the menu then I can just ask for something else".

Relatives of people told us they were happy with the service and felt that people are safe. They told us that they had no problems or concerns. Comments included "I've never had any concerns here" and "I'm confident it's safe".

Staff told us they felt "Supported" by their manager. We found that many staff had not received up to date training and supervision which could affect the care and support that was provided.