We inspected the service on 6 and 7 December 2017. The inspection was unannounced. Bramwell Care Home is a care home providing accommodation and personal care for people who live at the service. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bramwell Care Home accommodates up to 93 people across six units over two floors. On the day of our inspection 73 people were using the service.

At our previous inspection 15 and 16 November 2016 the provider was in breach of a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The concerns were around the lack of assessment of the risks to people’s safety, the lack of sufficiently skilled and experienced staff and the lack of systems in place to assess, monitor and improve the quality and safety of the service. During this inspection we found the provider had made significant improvements to the service and were no longer in breach of any regulations of the health and social care act.

A registered manager was in post and they were available during the 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People at the service were protected from possible abuse as staff at the service had the knowledge and understanding of the types of abuse people could be exposed to and how they should report issues of concern. Staff felt confident the management team would address any issues of concern and the registered manager fulfilled their responsibilities in dealing with safeguarding issues by reporting, investigating and acting on concerns raised ensuring that lessons were learnt from incidents.

The risks to people’s safety were regularly assessed to ensure they received safe care appropriate to their needs. Staffing levels met the needs of people and they received their medicines safely from staff who received appropriate training in medicines management. The cleanliness of the service was maintained and monitored and staff were knowledgeable on how to protect people from the risks of infection.

Nationally recognised and established assessment tools were used to assess people’s needs and staff received appropriate training for their roles. People were supported to make decisions and staff knew how to act if people did not have the capacity to make decisions to ensure their rights were respected.

People lived in a service which met their needs in relation to the premises and adaptions were made where needed. People had access to information in a format which met their needs.

People’s health and nutritional needs were well managed and staff acted on advice given to them by health professionals to manage people’s health and nutritional needs.

People were cared for by staff who knew their needs and preferences and were caring and kind towards them and their relatives. They were supported with respect by staff who maintained their privacy and dignity whilst encouraging and supporting their independency.

People received individualised care from staff who had the information they required to provide that care. People were supported to take part in a range of social activities and maintain relationships that were important to them. People were comfortable when raising concerns or complaints and felt issues raised were addressed to their satisfaction. People’s wishes in relation to their end of life care were supported with care and empathy.

The service undertook a robust auditing process to maintain the quality of the service. The registered manager worked with people, relat

This inspection took place on 15 and 16 November 2016 and was unannounced. Bramwell provides accommodation and personal care for up to 93 people with or without dementia and people with physical health needs. On the day of our inspection 79 people were using the service. The service is provided across two floors with passenger lifts connecting the two floors. Each area of the home was open so that people could access any of the communal areas in the service.

The service 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The risks to people’s health and safety were not always properly assessed and steps to reduce risks were not always taken. People were cared for in an environment that was not always clean.

There were not always enough staff to meet people’s needs in a timely way. People felt safe living at the care home and staff knew how to protect people from the risk of abuse. People received their medicines as prescribed and they were safely stored.

People were cared for by staff who felt well supported and received a range of training relevant to their role. We found the Mental Capacity Act (2005) (MCA) was being used correctly to protect people who were not able to make their own decisions about the care they received.

Sufficient quantities of food and drink were provided and people were generally positive about the quality of food. People received support from health care professionals such as their GP and district nurse when needed.

People were positive about the relationships they had developed with staff and felt well cared for. People were able to be involved in the planning and reviewing of their care and we saw they were able to make day to day decisions. People were generally treated with dignity and respect by staff.

There was a risk that people may not receive care in line with their changing needs because information about them was not always up to date or available. A range of activities was provided for people. However, people spent long periods of time without any activity or stimulation. Complaints were handled appropriately and in a timely manner.

The systems in place to monitor the quality of the service were not fully effective and did not always result in improvements being made. There was a positive and transparent culture in the home, people who used the service and staff felt able to raise any issues with the registered manager. There were different ways people could provide feedback about the service and their comments were acted upon.

During this inspection we found there had been improvements in service delivery and the care that people received.

People were asked for their consent and the provider acted in accordance with their wishes.

We received positive feedback from eight people using the service. People offered comments such as; “The staff are, kind and helpful.” “They ask me to join in their meetings. I sometimes go, if I feel like it.” “Staff ask my permission before helping me and are very attentive.” And “They explain what they are going to do.”

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

People using the service offered positive comments in respect of the care and support they received; “The home is great. Staff are brilliant. I’m happy with the care I receive.” “It’s been quite good recently because there are less people but staff generally come quickly when called for.” “Absolutely marvellous staff.” “Absolutely fantastic. Staff care for you, they don’t fuss after you. There is definitely nothing they could do better.”

We saw sufficient staff were available to support people. During the lunchtime meal people received the help and support they needed to eat their meal. Staff were encouraging people and monitoring their wellbeing.

We spoke with eight people in relation to the food served in the home. People generally gave positive feedback on the quality of the food and said they were given enough to eat.

Additional training had been offered to staff to ensure they had the necessary knowledge and skills to support people appropriately.

Two relatives we spoke with told us that staff had a good knowledge of their relative’s needs. One relative told us there had been some new staff employed who had a really good understanding of how to support people. They said, “They have some good staff who are here for the right reasons.”

Quality assurance systems had been improved upon to monitor service delivery. A relative told us that the management were responsive to any issues raised and their experience of the home was very positive.

A pharmacist inspector from the Care Quality Commission visited the home. This was in order to look at medicine management. There were 51 people living in the service at this inspection. We looked at the medicine administration records for 18 people and how the service stored and managed medicines.

The service had regular support from health care professionals. One member of staff told us ‘’we have a very good relationship’’ with the local surgery and a ‘’GP visits every week’’. We found that people’s medicines were regularly reviewed and changes made when necessary. The supplying pharmacy had visited the service on 6 November 2013 to check medicine management. We were told that ‘’it was a very positive visit’’ which included some recommendations. We found that action had already been taken following this visit to improve medicine management systems. This showed that the service had support from a professional healthcare team to ensure people were given medicines based on their current needs and lifestyle.

Staff who administered medicines had been assessed as competent. We were shown recent assessment checks for all staff who administered medicines. We observed one member of staff administering medicines to people at lunchtime. They offered support and allowed people time to take their prescribed medicines. A second member of staff told us ‘’we all help each other to make sure people have their medicines at the right time’’. This showed that arrangements were in place to ensure that people were given their prescribed medicines at the times they were due.

We found that arrangements were in place to ensure that medicines were managed safely.

We found that there were not enough qualified, skilled and experienced staff to meet people’s needs at all times.

All of the people we spoke with were positive about most of their experiences of Bramwell. Some people told us this was, at times affected by the number of staff available and whether they were permanent or agency staff. One person said, "I recently requested support to move someone, the agency staff just didn’t know or understand what was expected." One person said, "Staffing levels have been a concern. Mealtimes, particularly in the morning seem to be a problem when staff are not readily available.” We asked about the frequency of the concerns raised and the reply was “This is a frequent occurrence, definitely weekly.” A person who used the service said, “I don’t feel the staff rush me but they don’t have much time to spend with me to chat but if they have they do."

We also found that staff were not always available to supervise people who used the service and some people were not always supported to have sufficient fluids at regular intervals.

We saw that improvements had been made in the training of care staff to help keep them up to date and informed.

We were supported by an Expert by Experience during this visit. Experts by Experience are people who have experience of using care services. They take part in our inspections by talking to people who use the service and observing the environment. They have first-hand experience of receiving care and their findings are used to support our judgement on the service.

When we looked at care plans we found people’s needs were not always fully assessed and care and treatment was not always planned and delivered in line with their individual care plan.

People’s views about the care and support they received varied. Five people were positive about the care delivery and they told us staff supported them in a way they preferred. One person said, “The staff are very kind and compassionate, it is like a hotel here.”

Two people were not happy with the care delivery and one person told us there had been some delay in their pressure care and they had not started any physiotherapy exercises.

We found people were not always protected from the risk of inadequate nutrition. On examining peoples’ care files we saw that not everyone had been weighed in accordance with the instructions in their plan of care. Also assessments about people’s risk of malnutrition had not always been re-evaluated as required.

Three people told us they were happy with the meals provided and they were complimentary about the food on offer. Whereas three people were unhappy with the quality of the food and one person said, “Sandwiches are all bread, if you closed your eyes you wouldn’t know what the filling was.”

We saw most areas of the home were cleaned to the appropriate standard and one person using the service said the home was, “Ever so clean. Couldn’t be cleaner.” However we found people were not fully protected from the risk of infection because appropriate guidance had not always been followed.

We saw the environment was homely and areas were mostly suitably maintained. However we found the provider had not taken all the necessary steps to provide care in an environment that was adequately maintained in all areas.

We found there was not always enough qualified, skilled and experienced staff to meet people’s needs. All ten members of staff spoken with felt there were insufficient staff available to meet people’s needs. Five people felt there were enough staff to support them, whereas three did not.

We saw there were a high number of falls happening and a lot of these were not observed by the staff.

We found improvements were needed in respect of the record keeping to make sure these were up to date to ensure people received appropriate care and treatment.

People’s privacy, dignity and independence were respected. We spoke with two people who were using the service and they told us, “The staff are very nice, they always pop in to say hello and make sure I’m ok.” The other person said, “Yes the staff are nice to me.”

We spoke with two people who were using the service who told us, “I get the help and support I need and it is usually provided in a timely manner.” Another person said, “It’s alright, I like it here and the staff do their best for me.”

We spoke with two relatives of people receiving care. One person said, “My relative gets the basic care needs they require.” Another relative we spoke with told us, “Some staff seem to care but not all the staff act like this.”

We spoke with two relatives of people using the service. One person told us, “Staff seem so busy. I think they could do with at least one extra staff on every shift.” Another person told us, “There seem to be sufficient staff but they are not always visible.”

We spoke with two people who were using the service who told us, “I think there are enough staff. I don’t have to wait usually if I call for assistance.” The other person told us they were not sure if there were sufficient staff.

We spoke with two people who were using the service. Both of the people we spoke with said they felt they could raise matters with the manager and that they would be listened to.

We visited the location to carry out a planned review. We had also received some concerning information in respect of the quality of care delivered to people using the service.

We spoke with six people using the service, one relative and five members of staff.

One person who had recently started using the service said staff had asked them how they would like their care to be delivered.

All people we spoke with told us that staff spoke to them with courtesy and respect one person said, “The staff are wonderful, they are respectful and they speak nicely to me.”

Two people said there was enough information available to them to help them make decisions about their care and support.

A relative said the staff had been very helpful and they were kept informed of things. They said there were enough staff and they were happy with the care and support their relative received.

People using the service said they were happy and settled living at Bramwell and their needs were met. One person said, “The staff are 1st class, they are very willing and help me as needed, I am very fussy and these staff are wonderful.” Another person said: “I am happy and settled, the staff help me as needed.”

We spoke with people living at the service about how safe and supported they felt. All of the people told us they felt safe living at the home.

Two people using the service told us they received their medicines when they needed them.

People using the service said that staff were available to help them when needed, however two people did ask us where everyone was when there were no staff around.

One person said, “There are enough staff to help me, I do not have to wait long, but I am fairly independent.”

However, other evidence did not support this. Although the atmosphere was calm and staff were attentive to people’s needs we saw there were periods of time when people who needed to be were unsupervised. There were several times when there were no staff around in the communal areas as they were busy supporting other people with their needs.

People using the service said they could tell staff if they were unhappy about anything and they would be listened to.

One person said they had not had the opportunity to offer feedback via a questionnaire and there were no meetings they could attend.

This inspection took place on 3 and 4 February 2015 and was unannounced. Bramwell provides accommodation and personal care for up to 78 people with or without dementia and people with physical health needs. On the day of our inspection 73 people were using the service. The service is provided across two floors with passenger lifts connecting the two floors. Each area of the home was open so that people could access any of the communal areas in the service.

The service 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At an inspection in May 2013 we found that the provider was not meeting the legal requirements in respect of cleanliness and infection control and the safety and suitability of the premises. During this inspection we found that the provider had made the required improvements. People were cared for in an environment that was clean and well maintained.

People felt safe living at the care home and staff knew how to protect people from the risk of abuse. Relevant information about incidents which occurred in the home was shared with the local authority.

People were supported by a sufficient number of staff and the provider ensured appropriate checks were carried out on staff before they started work. People received their medicines as prescribed and they were safely stored.

Staff had the knowledge and skills to care for people effectively. We found the Mental Capacity Act (2005) (MCA) was being used correctly to protect people who were not able to make their own decisions about the care they received.

People received support from health care professionals such as their GP and district nurse when needed. Staff took on board the guidance provided by healthcare professionals in order to support people to maintain good health. People had access to sufficient quantities of food and drink.

Caring relationships had been developed between people who used the service and staff. People were involved in the planning and reviewing of their care and told us they were able to make day to day decisions. People were treated with dignity and respect by staff.

There was a risk that people may not receive care in line with their changing needs because information about them was not always up to date or available. People felt able to complain and complaints received were investigated in a timely manner. However, the outcome of complaints was not always recorded.

There was a positive and transparent culture in the home, people who used the service and staff felt able to raise any issues with the manager. There were different ways people could provide feedback about the service, although not everybody was aware of these. There were effective systems in place to monitor the quality of the service. These resulted in improvements being made to the service where required.