About the service:

Bramble House is a care home without nursing that provides a service to up to 29 older people, some of whom may be living with dementia or a physical disability. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

At the time of our inspection, there were 27 people living at the service.

Why we inspected:

We received a number of concerns through our intelligence monitoring of the service. These concerns related to staffing levels, infection control, medicine management, safe care and treatment and the environment. As a result, we undertook a focused inspection to look into these concerns and our findings are noted in this report.

We only looked at two key questions which were is the service Safe? and is the service Well-led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bramble House on our website at www.cqc.org.uk.

People’s experience of using this service:

There was no registered manager in post 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had left the service in December 2018 and the provider was actively recruiting for a new registered manager.

We found the provider had made some improvement following our previous comprehensive inspection on 24 and 26 April 2018. People could be assured that safe pre-employment checks were being followed when staff were recruited. The legal requirement to ensure fit and proper persons are employed were now met. People had received their medicines as prescribed.

However, some improvements were needed to ensure good medicine practices would always be followed to avoid breaching a legal requirement in future and to improve the service.

Regular audits in relation to health and safety, fire drills, call bell response times and people’s falls were still not being completed regularly. The provider might therefore not identify shortfalls in the service promptly so that action could be taken to prevent people for receiving unsafe care. Effective quality assurance systems were still not in place and the provider was taking action to establish a robust quality monitoring system. Improvements were still needed before the requirement in relation to Good governance would be met.

This was the second consecutive time the service was rated Requires Improvement overall. We met with the provider on 31 January 2019 to understand why progress against their inspection action plan had been slow. The provider told us due to significant staff turnover and the registered manager leaving the service was ‘running behind’ with improvements identified at our previous inspection. To prevent people receiving unsafe care whilst improvements were being completed the provider was spending more time at the service and monitored improvements.

We included the community nursing’s Care Home Support Team in our meeting and they agreed with the provider the support they could provide to enable improvement. We also informed the local authority that we were escalating our monitoring of the service due to the repeated Requires Improvement rating and the delay in improving the service to Good.

The provider had introduced a comprehensive audit tracker which would be used to check whether the monthly audits were being completed. Areas that would be audited included; care plans, medication, falls, accidents and incidents, health and safety checks, safeguarding and complaints. The provider told us an action pla

We last inspected in January 2017 and rated the service ‘Good’ overall. At this inspection we found improvements were needed and rated the service ‘Requires Improvement’ overall.

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.

An established registered manager provided the staff, people and their relatives with on-going support. Quality assurance systems were being used to review the quality of the service although the systems being used had not always been effective in identifying shortfalls and improving practices.

Staff knew people well and supported them to remain safe. However, the strategies used by staff to support people’s risks had not always been recorded in detail in people’s care plans. The management plans to support people with their risks did not always provide staff with adequate information on how to support people to remain safe. People’s medicine care plans were not sufficiently detailed to ensure staff would always know when people would require their occasional medicines.

The home had recently experienced changes in staff but were actively recruiting new staff to ensure staff would always be able to promptly meet people’s needs. We made a recommendation to support the service to make improvements to their staff management.

People could not always be assured that they were being supported by staff of good character as the systems used to recruit staff had not been robustly followed. On the days of inspection, we found that most staff, except some new starters had been fully trained in their role and plans were in place for staff to receive additional training.’ However some night staff and agency staff did not always have the skills required to meet people’s needs.

People enjoyed a home which was homely and provided a stimulating environment. People received care and support which was responsive to their needs. Staff were aware of people’s likes, dislikes and support needs. They were supported to maintain their health and well-being and access additional care and treatment from other health care services when needed. People were encouraged and supported to have a well-balanced and nutritional diet. People who needed special diets were catered for.

Staff were kind and compassionate to the people they cared for. People were treated with dignity and respect and their views were listened to. Relatives made positive comments about the approach and attitude of the staff. Staff were aware of their responsibilities to report any concerns of abuse or harm. Accident, incidents, concerns and complaints were reported and investigated into. Any incidents were reviewed and action was taken to improve the service being delivered. People’s health care needs were monitored and any changes in their health or well-being had prompted a referral to their GP or other health care professionals.

The registered manager and provider were making progress to make the improvements they had identified prior to our inspection. This included action to improve the home’s environment and the systems to monitor the running of the home. Actions were being taken to refurbish the home and equipment to support people.

We found two of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The inspection took place on 9 and 10 January 2017 and was unannounced. The service was last inspected in September 2014. There were no breaches of the legal requirements at that time.

Bramble House Care Home is registered to provide personal care for up to 29 people. On the day of the visit, there were 29 people at Bramble House.

There was a registered manager for 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.

Risks to people were minimised because staff understood what their responsibilities were in relation to protecting people from the risk of abuse. New staff were recruited only after an in-depth recruitment process.

People were cared for with kindness and compassion by the staff. The team had built up close, caring relationships with the people they supported their families and friends. The staff understood how to treat people as individuals and respected their lifestyle preferences, choices and wishes.

People were supported to eat meals that were varied and were nutritionally well balanced. Mealtimes were sociable events and people were able to invite their visitors to join them for meals. This meant that people were well supported and able to keep close contact with those who mattered to them.

People were cared for in a way that respected their privacy and dignity and promoted their independence. The home had a welcoming and friendly atmosphere. Close contact with family members was actively encouraged.

People who lived at Bramble House were being supported to enjoy a range of activities of their choosing. People enjoyed the activities and the opportunities made available to them. There were links with the nearby community and people were encouraged to be part of this.

The care and service people received was regularly reviewed to find out what improvements were needed, and how the service could be further developed. There were quality checking systems in place to monitor the service to ensure people received care that was personalised to their needs. Previous medicine audits had picked up some matters that required. The registered manager had acted on these matters.

The team spoke positively about the management structure of the organisation. They told us that the registered manager provided caring and supportive leadership. The staff team told us they were well supported by the registered manager. The registered manager was also very positive about their role and the team that they managed. Staff and visitors said the registered manager was always around and helped them whenever they needed any kind of advice guidance and support.

We have made a recommendation about the management of medicines.

The inspection was carried out by one adult social care inspector. The focus of the inspection was to answer two of the five key questions; is the service safe, is the service caring?

Below is a summary of what we found. The summary describes what we observed, what the staff told us and the records we looked at. We did not ask people who used the service direct questions about their care because of their dementia; instead we used the SOFI observation tool in one of the communal areas.

Is the service safe?

People were safe because there were arrangements to give and store their medicines safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People were safe because the service had proper policies and procedures in place in relation to this. Where people were deprived of their liberty in order to keep them safe this had been done lawfully.

Is the service caring?

The service was caring because care was planned and delivered to people in a thoughtful and kind manner.

In this report the name of a registered manager appears who was not managing the regulated activity at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time. We have advised the provider of what they need to do to remove the individual's name from our register.

During our visit we spoke with three people who were able to express their views of living in the home. They all told us they were happy living in the home, staff treated them well and they enjoyed their meals. People told us “They (staff) are very kind to me” and “The food is good, I have no complaints”. Other people were unable to express their views because of their communication needs. However, we spent time observing people in the two lounges during the lunchtime period. Staff interactions were respectful and at the pace of the person they were working with.

We also spoke with two visitors and they told us the home was very friendly, welcoming and homely. A visiting nurse told us the home was open to advice and was willing to work with health professionals.

Care plans were personalised to each individual's needs and detailed how staff should work with people to meet those needs. Risk assessments had been completed where appropriate and all care records were reviewed monthly.

The environment had adapted to help people with dementia orientate themselves around the home. This included the use of clocks and notice boards, bedroom door names, memory boxes outside bedrooms and contrasting colours of doors, table cloths and cutlery.

We found some shortfalls in record keeping because there was insufficient detail recorded in mental capacity assessments completed for day-to-day decisions and nutrition intake charts.

The vast majority of people who live at Bramble House Care Home have dementia; therefore we did not ask them direct questions about their care. We did undertake observations of how staff interacted with people during our evening visit.

Before this responsive review we received information which gave us a number of concerns about the service provided to people at Bramble House.

At this scheduled inspection we also followed up on a compliance action issued on 11 December 2012. We were unable to ask people about their views of living in the home because people had a diagnosis of dementia and as a result had some communication difficulties. However, we observed that staff understood the best way to communicate with people and were able to support people to make choices about their daily living.

We looked at the care plans for six people and saw that these detailed how people communicated their wishes and if they had the capacity to make daily decisions. Care plans were person-centred, reflected people’s current needs and wishes and were regularly reviewed.

Appropriate arrangements were in place in relation to the recording and storage of medicine. People were made aware of the complaints system and the home gave clear information to people about how to complain. Staff we spoke with told us they enjoyed working in the home, received good training and felt supported by the manager.

The compliance action issued on 11 December 2012 was met as assessments for people’s capacity to make day-to-day decisions had been reviewed and updated. The format used for completing food and fluid charts had been updated and charts recorded details of exactly how much people had eaten and their level of fluid intake.