Bramcote Hills Care Home

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• 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

We identified three breaches of the legal regulations relating to this key question. There were not enough skilled and trained staff to support people with their support needs. The management team failed to review staffing levels regularly to make sure there were always enough staff on duty. Staff had not received relevant training to meet the range of people’s care needs. Safety risks to people were not managed well. The management team did not assess and review safety risks with people to ensure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. People and those important to them were not supported to understand safeguarding and how to raise concerns when they did not feel safe. Staff did not receive support through one to one meetings or staff team meetings. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to the management team. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk. The management team made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not provided with an opportunity to be involved in any learning at Bramcote Hills Care Home. For example, Systems and processes were not in place to involve people who had experienced accidents or incidents. This meant learning from incidents did not take place in order to reduce the risk of it re occurring. People told us they were not involved in discussions or reviews on how to improve the quality of care at Bramcote Hills Care Home. People were not provided with an opportunity to speak up if they had a concern. This meant the provider and management team could not learn and make the required improvements to peoples care and support if needed.

There was not a culture of safety and learning. Staff told us management had not offered any opportunity to reflect and review what was working well, and what could be improved at the service. Staff could not explain to us what learning had occurred when incidents had happened or when things went wrong to ensure they did not occur again. Staff were not encouraged or supported to raise concerns. Staff were not involved in any learning which meant staff were not empowered to be involved to improve their practice. The manager told us they did not complete any reflective practice or debriefs when an incident of accidents occurred to allow learning to take place. This meant people were at risk of incidents and accidents re occurring

The provider failed to ensure there were systems and processes in place to enable a learning culture. We found that there was no process or system in place to learn and reflect when things went wrong or from incidents and accidents. We found similar incidents had repeatedly re occurred and placed people at risk of harm. Staff and people living at the service were not provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. The safeguarding policy included the duty of candour. This policy guided staff to tell the person (or, where appropriate their advocate) when something had gone wrong. People were not involved in reviewing or learning from incidents; therefore, we were not assured the provider had followed their policy.

People had not experienced safe systems, pathways and transitions. For example, a person living with diabetes had a health professional involved and guided the clinical staff on safe processes and procedures. The health professional visited over 3 times and found clinical staff had failed to follow the safe glucose management plan at each visit. After our onsite visit we were notified the continued poor management of diabetes resulted in a person being admitted to hospital. This placed the person at significant risk of harm.

Staff had not received consistent information or guidance to ensure safe systems were established for people. Care plans were not reflective of people’s health care needs. Staff told us they were only provided with basic information when a person was newly admitted into the care home and if they were not at work at that time, they would have to ask other staff or learn while they were supporting the person. One staff member told us “If there is a new resident or if someone’s needs have changed, the information is passed on informally via peers or observation of changes. Care plans will have the information eventually but often late to be updated. There is some miscommunication. If been on leave for example can miss changes to care and won’t be told before start working. Don’t get told why care may have changed, what the reasons were for it.” This meant people were at risk of harm by not being supported appropriately.

Prior to our assessment, partners told us communication between staff, people living at the care home and health providers was poor. Health professionals told us they found it difficult to contact staff at the care home, especially during the evenings and weekends. Other health professionals told us a person had been transferred from hospital, however the care home staff were not aware of the person arriving and resulted in a poor transition for the person.

The care home did not have clear processes in place to ensure there was effective communication between people living at Bramcote Hills, health professionals and staff. The provider did not have processes in place to ensure there were clear summary documentation on people’s holistic needs that could be shared during transitions. This meant if a person required a hospital admission, hospital staff would not have clear guidance on how the person liked to be supported.

People and relatives raised no concerns around safety. People told us they felt safe from abuse. One person said “I do feel safe. The staff do what they can’.” People told us there were unlawful restrictions imposed on them. One person who had capacity to make their own decisions, had bedrails in use. However, they told us they were not aware they had the freedom to make the decision not to have the bedrails up. This meant people were at risk of institutional abuse. People were not free to complete their own routines and live their lives as they wished. We found that people would call for help and there were not enough staff to respond. Some people would be at risk if they did not have continuous supervision and control. Where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

Staff understood how to respond to allegations of abuse. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. Staff were confident in using whistleblowing processes if they felt concerns were not being responded to. The registered manager understood how to respond to allegations of abuse. They had a clear process of how to investigate and keep people safe. Staff knew where to find the safeguarding policy. They were aware of the policy guidance and knew how to follow it to keep people safe from potential abuse.

People were at risk of neglect and harm. We observed people were at risk of neglect. A person was in bed soaked in urine and shouted staff for help. We observed a staff member walk past and ignore the person asking for help. We observed a second person with dried faeces on their clothes and bedsheets. Additionally, we saw an incontinence pad left on their bedroom floor with dried bowel movement. We were not assured that staff had supported them to maintain their dignity or adhered to infection control measures. This meant people were at risk of neglect and harm.

The provider did not have a system or process in place to audit incidents and accidents. This meant there was no system in place to allow management to identify potential risks hazards to make the necessary changes to ensure people were supported safely. The provider did not have a system in place to ensure people were always safe when they were in communal areas. Staff were not deployed effectively to meet people’s needs to maintain their safety. People living at the care home were at risk of harm due to insufficient staffing levels across the five floors of the home. For example, we observed a person have two near misses of falls due to no staff supervision. The person was holding a hot drink and it had spilt on them. This meant the person was at risk of harm from falling and scalding. We found The Mental Capacity Act was not always followed. Where people were deemed to lack capacity and best interest decision were made, the provider had not completed a mental capacity assessment in line with the Act. This meant people had unlawful restrictions imposed on them. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. If an allegation of abuse was made, there were appropriate processes and policies in place to guide the staff team. Records showed that incidents were referred to the local authority safeguarding team if needed.

People were not involved in the management plans regarding risks. People told us they were not provided with an opportunity to communicate their needs, to ensure they were involved to manage their risks. People and relatives where required had not been involved with care planning. One person said, “No one has talked about a care plan. I didn’t know I had one.” One relative said they had “not been involved in [person]’s care plan and I didn’t know there was one.”

The management team told us they had completed an audit of care planning documents and risk assessment and identified these required updating to be reflective of people's needs. The management team could not demonstrate or explain what action had been taken to action the identified shortfalls within peoples care plans to ensure staff had clear guidance to follow.

People were not supported to manage their identified risks to ensure they were always safe. We observed people were left unsupervised consistently in the communal lounge/dining room. However, one person had identified risk of verbal and physical abuse towards staff and service users. We found there were not sufficient staff on duty to allow supervision to ensure people were safe from verbal or physical abuse. We also observed that a person was in bed, with bedrails in use without staff supervision and without any means to alert staff they needed support. This meant the provider had failed to ensure peoples identified risks had appropriate risk management plans in place.

The provider did not have systems in place to ensure people were involved to manage risks and ensure staff were provided with reflective guidance on how to support people with risks. People’s care plan demonstrated people who were important to them were not involved in managing risks. When people had displayed periods of emotional distress, we saw not all of these incidents were documented. There was not always guidance, care plans or risk assessments to show how to support people during these times. People at risk of falls remained at risk as staff had not ensured appropriate measures were in place. People who were supported in bed were left for prolonged periods of time without staff supervision. People who required support with diabetes did not have care plans in place. This meant staff were not provided with clear information and guidance regarding how to support people with their glucose levels. Overall, the provider failed to ensure staff had the information they needed to manage risks such as distressed behaviour, falls, diabetes and people cared for in bed. This mean there was no system in place to ensure people’s risks were assessed or reviewed as their needs changed. There was no system to ensure staff had all the information they needed to provide care that met people’s needs.

People did not always experience a safe environment. People felt the environment was managed safely. However, we found a person had not been provided with a call bell in their bedroom. This meant they could not request staff support if needed. People could not explain if they had been part of practice emergency evacuation such as fire drills. This meant there was a risk people did not know how to evacuate the building in an emergency.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns to. Staff were confident that the building was well maintained. The management team described a clear process for monitoring the safety of the environment. For example, the registered manager documented their regular checks around the building and explained how they passed concerns to the maintenance team to resolve. We saw that any areas they had picked up, had been resolved to keep people safe. Staff told us they knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space. However, due to our observations we were not assured staff fully understood fire regulations.

We found some windows could be opened wider than the guidance from the Health and Safety Executive. This meant there was a potential risk people could climb out. We found staff failed to understand fire regulation. A fire door had been wedged open in a communal lounge. Staff told us “staff always do that”. This meant the door would not close in an event of fire and provide the protection it should, which could cause a risk to people. The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment.

Equipment and the environment had not been safely maintained. The provider had not ensured regular checks and maintenance was completed as required. We found regular checks had not been completed. For example, a fire alarm was due to be serviced in April 2024 and the management could not provide assurances this had been completed. Management had not taken action in line with the homes current fire risk assessment. For example, the exit door within the conservatory had been identified needing a thumb turning lock. We found a conservatory door did not have this type of lock. Personal Emergency Evacuation Plan (PEEPs) were not reflective of people’s mobility needs. For example, one person’s plan stated they walk independently but there was no record to ensure staff and emergency service would be aware the person needed verbal support and support to know where the nearest fire exit is. Without this support, they would not be able to evacuate the building independently. This places people at risk of harm. We found hoists and other equipment’s service dates had expired and these had not been tested to ensure they were in good order and safe to use. This placed people at risk of harm. Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like legionella) The gas heating system was regularly serviced to prevent harm to people.

All the people and relatives we spoke with told us there was not enough staff, and they were not responded to quickly. One person said, “There should always be someone [staff] in this room (lounge). If someone falls, there’s no carer. I think it’s when they go for breaks or putting people to bed. There’s someone here during the day, but not in the evening. I wouldn’t know how to find someone.’’ We observed a person distressed and shouting for the Inspector to come into their room. The person was in bed soaked in urine, shouting out for staffs help. There was no call bell for them to alert staff they needed support. They told us they had been shouting for over 45 minutes and had been ignored by staff.

Staff told us there were insufficient staffing levels. Staff comments included, ““I agree 100% there is not enough staff. Some days I feel like crying it is so stressful’.” Another staff member told us, “Couple of staff have left. Managers have got staff levels wrong.” And “To be honest we are really short of staff, really need more due to the floors and number or residents, we need extra pairs of hands.” Staffing hours in the kitchen were reduced. There was one cook and one kitchen assistant between 8am -2pm for 49 people. After 2pm care staff were required to support the kitchen staff meaning even more staff were taken away from supervising or supporting people that used the service. This meant people were at risk of not being supported in line with their assessed needs and at risk of harm. Staff told us they had not had regular opportunities to meet their manager on a one to one basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance/training if needed. One staff member told us, “I have not had any positive feedback since being there. I have not had a formal supervision/appraisal yet.”

There were insufficient numbers of staff to provide a safe level of care. During our onsite assessment, we observed repeated concerns relating to staffing levels. Staff were not deployed effectively to people’s needs to maintain their safety. People living at Bramcote Hills care home were at risk of harm due to insufficient staffing levels across the five floors of the home. When staff supported people with 2:1 care such as transfers, incontinence and personal care, the remaining service users were left unsupervised. Staff told us there were no staff to replace them. We are concerned that this left people at increased risk of harm. Throughout our onsite assessment, call bells were consistently going over the providers three-minute response time. This meant people needs were not met in a timely manner. People told us they waited long periods of time and when staff did respond they would be asked to wait. We observed there were not enough staff to allow people to move freely around the home. When people stood up to leave the lounge, staff encouraged people to sit back down and supported them back to their seats. This meant people were at risk of restrictive practice that breached their human rights. We saw staff were suitably trained to complete their roles. Staff used their training to respond effectively to people’s moving and handling needs.

Staffing levels were insufficient to meet people's needs and keep them safe. The provider failed to ensure there were clear processes to ensure there were enough staff. The provider had not used a calculation tool or any other means to assess how many staff were needed to meet people’s needs. This meant the provider was not aware how many staff would be needed on each shift to keep people safe. During our onsite visit we observed incidents had occurred because there was not enough staff to keep people safe. We found communal areas and bedroom floors left unsupervised for prolonged periods of time while staff were supporting people. There was no system in place to ensure when staff were supporting people who required support, that there were other staff to supervise people for their safety. Insufficient numbers of staff places people at increased risk of harm. Staff had not completed appropriate training to do their role safely. Staff had not completed training in positive behaviour support, dysphagia, skin integrity, risk management, person centred care, nutrition and hydration and equality, diversity and inclusion. This meant staff did not have the skills, knowledge or understanding on how to support people who required support in these areas to ensure they were protected from the risk of harm. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had also had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people. The service employed some nurses. These nurses were registered with the regulatory body (The Nursing and Midwifery Council). The management team completed regular checks to ensure their nursing registration was maintained.

People were at risk of infection due to poor management of infection prevention and control. For example, a person’s falls sensor mat was not working. Staff took a sensor mat from another person’s bedroom but did not clean it before placing it in another person’s bedroom and it was dirty. People told us that the home was kept clean. We found people’s bedrooms were kept clean and tidy.

Staff told us they had completed infection prevention training. However, we were not assured all staff understood the training and the risks of not following infection prevention guidance because of what we observed during our assessment.

The home was not always ensuring they had robust infection prevention practices in place. On entering the care home, the main corridor had a strong smell of urine which appeared to be from the flooring. We found a shower chair that was dirty and had dried faeces on. We saw the kitchen was not managed in a hygienic way to ensure people did not get food borne infections. The most recent check from the food standards agency had rated the service 3 stars on the 11 August 2023. The rest of the home was found to be generally clean and tidy. Housekeeping staff were seen to be present and cleaning. We saw that staff had access to personal protective equipment (PPE) like gloves and aprons throughout the home. This allowed them to support people in a hygienic way. However, staff failed to dispose their PPE in a clinical waste bin. This meant there was a risk of contamination.

We observed the kitchen to be extremely dirty and not kept in line with IPC guidance. The floor was dirty and had not been cleaned. The hot food trolley had burnt long standing stains and dried food stains. There were no systems in place for when this was to be cleaned. The food hygiene standard agency had rated the kitchen a 3. There was no action taken to make the necessary improvements. Robust cleaning schedules were not in place to ensure all areas of the care home were covered to ensure the environment was kept clean and hygienic. This meant people were not always protected from the spread of infection. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

Medicines were not always given safely because the manufacturers' instructions were not followed properly. We were not assured people were given medicines which should be given before food were not given at the same time as medicines that needed to be given after food. This meant the medicines may not have been effective or avoidable side effects could have been experienced. People told us that they were not involved with reviews of their medicine. This meant people were not provided with an opportunity to understand their medicines support and care.

The management team and clinical staff were able to explain their processes and systems for medicine management. However, records demonstrated that staff were not following safe medicines management processes. This meant we were not assured following the management feedback that management and clinical staff were competent in following safe medicines practices.

Medicines were not managed safely. People diagnosed with diabetes were not always being supported appropriately. For example, 4 people out of 5 did not have care plans or risk assessment in place regarding the management of their blood sugar levels to keep them safe. We found blood sugars were recorded inconsistently and missing information regarding the times of checks and times of administration of insulin. This places people at risk of harm. Staff did not have a system in place to ensure time critical medicines such as Parkinson’s medicines were administrated on time. Staff did not record the actual times they administered time-critical medicines; therefore, we were not assured people had received these medicines on time. We also found the provider failed to ensure topical medication was stored correctly. We found topical medication that were accessible and unsecured in people’s bedrooms. This increased the risk of harm to people if used or ingested. Furthermore, we found a topical medication that should have been stored in a fridge in a person’s bedroom. This meant the medicines may not have been effective. Medicine administration records for all Service Users had handwritten medicines entries that had not been signed by two staff members to confirm the transcribing was correct. This is not in line with National Institute for Health and Care Excellence guidance of Managing medicines in care homes. This practice increases the risk of errors and places people at risk of receiving their medicines unsafely. Staff had received training on how to administer medicines safely. The management team had not regularly assessed the nurse’s competency, this was due the management not being medically trained. Staff told us this was completed outside of the organisation.