About the service: Bramley Grove is a care home for up to 34 older people who may be living with dementia and require support with personal or nursing care. At the time of the inspection 33 people were living at the service.

People’s experience of using this service:

People’s experience of using the service was positive. People told us, “I am blessed to have this home and I hope it will be my last”, “The staff here are very calm and patient and never seem as though they are in a rush”, “I am impressed how they are building the networks so people have good social contacts” and, “I am so impressed with the care here.”

People were mostly protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe, although not all environmental checks had been carried out. Risks to peoples health and well-being were assessed and measures put in place to reduce these. Risks in the environment were not always checked in a timely manner. Staff received supervision, support and training, which provided them with the knowledge and skills to perform the roles they were employed to do.

Care was person-centred and focused on people being as independent as they could be. The care was planned and delivered based on people’s needs and preferences. The management team embraced continuous learning and new ways of working. Staff felt valued and the culture was open and honest. Staff we spoke with provided positive feedback about the service and the provider. The staff were committed to ensuring improvements continued to ensure the best care for people who lived at Bramley Grove.

Rating at last inspection: At the last inspection the service was rated Good. (The last inspection report was published on 21 April 2016.) At this inspection the service was rated as requires improvement in well led and remains good in all areas and good overall.

Why we inspected: This was a planned comprehensive inspection scheduled to take place in line with the Care Quality Commission (CQC) scheduling guidelines for adult social care services.

Follow up: We will review the service in line with our methodology for ‘Good’ services.

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

This inspection took place on 14 March 2016 and was unannounced. When we last inspected this service in September 2014 we found it compliant with all the regulations we looked at.

Bramley Grove is a care home without nursing for up to 34 people, some of whom have dementia. At the time of our visit there were 34 people using the service of whom four were in hospital. The property is a purpose built care home and accommodation is on two floors with a passenger lift to facilitate access. The ground floor unit is known as “The Brambles” and the first floor unit as, “The Willows.”

At the time of the visit the home had a registered manager. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was unavailable during our visit but we spoke with them the next day on the telephone.

People who used the service and their relatives told us that the home was safe. Staff were aware of the need to keep people safe and they knew how to report allegations or suspicions of poor practice.

People were protected from possible errors in relation to their medication because the arrangements for the storage, administration and recording of medication were good and there were robust systems for checking that medication had been administered in the correct way. However we saw that medication records were not always updated promptly.

People who lived in this home and people’s relatives, told us that they were very happy with the care provided. People had opportunities to participate in a range of activities in the home and community, but if they chose to spend time engaged in hobbies in their rooms, this choice was respected.

People’s relatives and friends were made welcome by staff and there were quiet areas where people could entertain them.

People and, where appropriate, their relatives, were consulted about their preferences and people were treated with dignity and respect. However several people said that people’s laundry would sometimes go missing.

Staff working in this home understood the needs of the people who lived there. We saw that staff communicated well with each other and spoke highly of the management and leadership they received.

Staff were appropriately trained, skilled and supervised and they received opportunities to further develop their skills.

The manager and staff we spoke with understood the principles of protecting the legal and civil rights of people using the service.

People were supported to have their mental and physical healthcare needs met and were encouraged to maintain a healthy lifestyle. The manager sought and took advice from relevant health professionals when needed. Health professionals told us they were pleased with the support people received.

People were provided with a good choice of food in sufficient quantities and were supported to eat meals which met their nutritional needs and suited their preferences.

There was effective leadership from the manager and senior members of staff to ensure that staff in all roles, were well motivated and enthusiastic. The manager assessed and monitored the quality of care consistently through observation and regular audits of events and practice.

The manager consulted with people in the home, their relatives and visitors to find out their views on the care provided and used this information to make improvements, where possible.

We inspected this service to follow up on our inspection in April 2014 where we had concerns about the service's ability to administer medicines safely. One inspector carried out this inspection.

There were 32 people living in Bramley Grove at the time of our inspection. The summary is based on: observation of the administration of medicines in one of the unit's dining rooms during breakfast, speaking with two staff who administered medicine in the home that day and speaking with the manager. We also looked at relevant medicine records for six people and systems the home had to ensure people received medications safely.

Our observations showed that people were appropriately supported to take their medicines. They were not rushed and they were approached in a kind and caring manner.

Staff completed thorough checks that people had taken their medicines before recording this information. Counts of medicine held in the home matched the provider’s own records and the person's individual prescription.

Medicine was kept securely at an appropriate temperature and was available when needed. The arrangements for disposing of medicines had improved.

There was appropriate information about what each person’s medication was for. Arrangements were in place to review people medicine needs and act in their best interests where needed. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Staff who administered medicines were knowledgeable about specific people's health conditions, the medicines people required to keep well and knew where to get further information. There was evidence that staff competence to administer medicines had been reviewed and that action had been taken if there were concerns about this.

We judged the administration of medicines to be safe.

Our inspection team was made up of two inspectors who considered our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them, the people who commission the service and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that the care provided in Bramley Grove was safe. The home was accessible, clean and well maintained. We found there was appropriate attention to infection control in the laundry, kitchen and in the day to day provision of people's care. People's care needs and risks were assessed and planned for and this ensured that risks of harm to people were minimised. There were sufficient numbers of staff on duty that had the appropriate skills and experience to ensure that care was delivered as planned. Recruitment practice was safe and thorough. We spoke with relatives and staff who told us that the care provided and the service provided was safe. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards applications had been submitted when needed. There were no deprivations of liberty in place at the time of the inspection. People generally received their medicines at the right time and however further checks were needed to ensure that all medicines were accounted for.

Is the service effective?

Both relatives and staff told us the service was improving. We looked at the complaints records and found that these had been recorded well, investigated without bias and where shortfalls found actions had been taken to try and improve the situation. For example, in response to previous complaints care staff who have more knowledge about individual's clothes had been given a greater role in locating and returning “missing” items. In addition checks were being made of the clothing in people's wardrobes.

We observed the breakfast meal time in both units. We saw that people had a choice of breakfast meal. The kitchen staff were given the details of people's weights and informed if people were increasing or decreasing in weight. They were allowed to check an individual's care plan in respect of nutrition and see what measures were recommended to improve people's weight. For one person we looked at this had resulted in an appropriate increase of weight.

During observations we saw that care staff were alert and effective in minimising some of people's behaviours that could be perceived as challenging such as, collecting other people's belongings and lifting walking frames in a dangerous way.

Is the service caring?

During our observations we saw that people were supported by kind and attentive staff and this ensured that people were supported to eat, maintained domestic abilities and conversation. Relatives we spoke with and comments from other relatives included: "They are respectful of residents and do their best to keep them active, they are caring" and "They are caring and they work as a team, they work very hard."

People's preferences, interests, social history and diverse needs had been recorded in people's care plans. We saw that people were dressed in the way their care plan said they preferred. Amongst relatives comments were that people's appearance was attended to and people looked well cared for.

Is the service responsive?

People were supported to attend doctors, dentists and other health appointments on a routine basis and when needed. We checked some care plans for people who had conditions that may suddenly deteriorate and found that appropriate measures were in place to monitor these conditions and respond if needed.

We looked at care plans of people who had incidents and accidents recently. We found the relevant care plans for the person concerned had been updated and where necessary new actions added to ensure their needs were met. We also checked the plans of some people who can have behaviour that challenges other people living in the home. We found that health professionals were contacted if this happened and records were kept of each incident so as to assist health professionals and determine triggers and treatment.

Is the service well-led?

Since our last inspection the manager has been registered with us. Relatives and care staff we spoke with told us the service was improving. There have been efforts made to ensure that concerns and complaints are robustly investigated and action taken. The management has showed that they improved in listening to staff and relatives and where concerns have been raised these have been shared in staff meetings to try and ensure consistency in communication. We saw audits in progress to ensure consistency of care records and these had ensured that standards had improved.

Following our previous inspection in July 2013 we issued a warning notice because: the home's systems did not ensure that risks to people's safety and well-being were identified and lessened, and that shortfalls in the quality of the service had not been identified and improved. We had other the concerns about the staffing levels which limited staff's ability to provide appropriate care and welfare of people.

We visited Bramley Grove unannounced on Sunday 3 November 2013 to follow up on these concerns. We carried out observations and spoke with the relatives of four people, and with staff during our inspection. We found that there had been improvements. These included: a reduction in the number of incidents and accidents and an improvement to the systems by which people could raise concerns or complaints. The signposting in the home had improved with photographs of the relevant person on bedroom doors, signs and objects to help people with dementia recognise where they are in the building. There were more activities and records of these activities were kept. A relative told us that: "The activities coordinator is fabulous..."

We found that staffing levels at the weekend remained low and although people did not have hurried care there was not enough capacity to ensure staff had time to deal with emergencies or ensure that people could be given baths or showers in the morning. Staff were not always able to tell us about people's past and this could mean that people were not receiving individualised and consistent care. Amongst relative's comments were: "The care fluctuates from fair to good" and "Staff feel overworked."

Relatives told us that problems remained with the laundry service provided. We looked at the laundry provision and found that the proposed changes to the laundry had yet to be completed. This meant that the service provided was inconsistent and people still found other peoples clothing had been placed in their rooms.

Most of the people living in the home were unable to say how they would like to be supported. During this inspection we spoke with five people, we observed people's care in both lounges throughout the day and we spoke with three relatives. We observed people's care throughout the day.

People told us that care staff were kind, they told that they were able to make choices of: when they retired to bed, what to eat and whether to join in activities. People told us about Tai Chi sessions and a person that came in to do exercises. However they also said: "That's all they do here," and "They don't offer me anything else."

Since our last inspection in April 2013 there had been some improvements to people's care and appearance however this was not consistent. Some of the relatives we spoke with told us there still issues with: the attention to people's laundry, activities, the deployment of staff and the lack of action on their concerns.

We found that the planning of care and the minimising the risks to people needed improvement including when people: fell or had behaviours and care needs associated with their dementia. Permanent staff tended to work during week days leaving agency staff covering shortfalls mainly at weekends and nights. There were insufficient systems to identify and respond to these concerns.

When we visited Bramley Grove we found that care staff spoke with people that lived at the home kindly and appropriately. People most of the time were observed to show well being by smiling and being happy to talk with us. All the people that lived in the home had dementia. Those people who could answer some questions thought the home was good. We found that the home had appropriate systems to ensure that people's liberty was not taken away from them without involvement of people that know and work with them.

Some people became upset with other people living in the home and on occasions people got hurt. Safeguarding procedures were not followed. This meant that opportunities to find the cause of people being upset and minimising the risk of harm was lost.

Staffing levels in parts of the home were not high enough to ensure that people had opportunities for social interaction and support. In addition there was no registered manager and the managerial support at the time of our visit was temporary. This had led to lack of overview of risks such as accidents and consistency in the quality of care. Recently the provider had arranged some extra support and some systems were being put in place to respond to concerns, to review accidents and to monitor people's well being.

We carried out this review to check on the care and welfare of people using this service as we had not visited it for some time and had limited information on the quality and safety of the service being provided.

Thirty-one people were living in the home when we visited. We spoke with three people living in the home and the relative of one person. We also spoke with two members of staff, the home’s temporary manager and a senior manager from the registered provider’s management team. This helped us to understand what it was like to live there.

The people living in the home and the relative told us that they were happy with the quality of the care provided. One person said “The staff are friendly” and “Everything’s all right.” However, we saw that some staff did not give people their full attention. They spoke with them but then walked away, so they did not know if the person had anything more to say or not.

The home appeared clean and one person told us “It’s clean.” However, we noticed a slight odour in one of the common rooms we went into and one person showed us into their room which had an odour in it. Staff told us there were plans to change their carpet.

People indicated they were happy with the meals provided at the home. One person told us the lunch was “okay.” They said they had enough to eat.

Most of the people living in the home were unable to say how they would like to be supported. Systems to ensure that their personal care and appearance were attended to were not consistently in place. Some of the relatives we spoke with told us there were issues with: the laundry, the lack of management of people's resistance to personal care and lack of team work amongst the staff. This resulted in poor attention to people’s appearance. We found that when people were upset care staff did not have strategies individual to the person to manage the situation. We saw whilst care staff were kind, at times, the home's routines did not take account of choices people had made.

People had not taken part in many activities and comments made by relatives included: "The home is dull," "There are no activities," "They are starting to do more activities now." We saw that an activity coordinator had been appointed however there was not enough strategies and support for people who were unable to join in group activities.

A large number of agency staff had been working in the home. Further permanent staff were being recruited. We found that there were not enough staff available to ensure that all of the needs of people living in the home were met.

The provider's own assessment of the quality of service that people receive had identified similar issues. We were told of some actions that were being taken to improve.

You can see our judgements on the front page of this report.