CQC report explained · a residential care home
What the CQC found at Brambledown Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, and staff managed risks, safeguarding and medicines safely. Inspectors found some safety and cleanliness issues, including windows, fire risk assessments and hand-washing facilities, but several were corrected after the visit.
- Effective?
- Good
- This area was not assessed in this inspection.
- Caring?
- Good
- This area was not assessed in this inspection.
- Responsive?
- Good
- This area was not assessed in this inspection.
- Well-led?
- Requires improvement
- The home had been without a permanent manager, and oversight was not consistent. The new manager had identified improvements needed, but some care reviews and actions on the improvement plan were overdue.
What inspectors found, March 2023
Brambledown Road rated Good; inspectors found safe care, but leadership and some follow-up work needed improvement.
The inspection was unannounced and took place on 15 March 2023. One inspector met all seven people living at the home, spoke with relatives and staff, and checked care, staffing, medicines and management records.
The home was rated Good for safety. Inspectors found enough staff to keep people safe, medicines were managed safely, and staff understood people's risks and how to protect them from abuse. Some issues with window restrictions, fire risk assessments and hand-washing facilities were found, but the home provided evidence that several of these were fixed after the visit.
The home was rated Requires Improvement for being well-led. It had been without a permanent manager, and some checks, care plan reviews and improvement actions had not been completed promptly. A new manager had started and was beginning to address these problems.
The overall rating was Good. The previous overall rating was also Good, published in July 2018, but the well-led rating fell from Good to Requires Improvement.
Safe staffing
Inspectors found enough staff to meet people's needs and provide one-to-one support when needed.
“The service had enough staff, including for one-to-one support for people, to ensure people's safety and welfare.” from the report
Risk management
Staff understood people's individual risks and supported them in a personalised and least restrictive way.
“People were involved in managing risks to themselves and in taking decisions about how to keep safe.” from the report
Medicines
Medicines were administered, recorded and stored safely. The home also reviewed medicines in line with reducing unnecessary medication.
“Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people's medicines were reviewed by prescribers in line with these principles.” from the report
Safeguarding
Staff knew people well, understood how to protect them from abuse and knew how to report concerns.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Leadership gap
needs fixingThe home had no permanent manager for several months. This meant there was not enough oversight to make sure good practice was consistent.
“during the months preceding our inspection there had not been adequate oversight and leadership at the service to ensure consistent and sustained good practice.” from the report
Activities and community access
needs fixingStaff and relatives were concerned that staffing changes could reduce people's engagement and opportunities to go out into the community, even though safety staffing levels remained adequate.
“there were concerns from staff and relatives that recent changes to staffing levels were impacting on the level and quality of engagement with people at the service and opportunities to access activities in the community.” from the report
Fire and window safety checks
needs fixingTwo bedroom windows were not adequately restricted, and fire risk assessments did not fully reflect the needs of people living upstairs. The windows were fixed after the visit, while the fire assessments still needed updating.
“We also found that fire risk assessments needed updating to take account of people's specific needs on the first floor to ensure people remained safe in the event of a fire.” from the report
Overdue reviews and improvements
needs fixingCare and support plans had not always been reviewed as planned, and some improvement actions had been left open for a long time. A planned deep clean identified in April 2022 was still incomplete in February 2023.
“people's care and support plans had not been reviewed as regularly as planned due to the time spent without a manager.” from the report
- 01What has the new manager completed since the inspection, including the review of all care and support plans?
- 02How do you now staff the home so people can take part in activities and go out into the community?
- 03Have the fire risk assessments been updated to reflect the needs of people living on the first floor?
- 04How do you make sure bedrooms and other areas remain clean and hygienic?
- 05Has the new manager applied to become the registered manager, and what quality checks are now being completed regularly?
This was a focused inspection of Safe and Well-led; the report does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 29 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Good; inspectors found kind, personalised care, with some safety and management issues to check.
This was an unannounced inspection on 22 May 2018. Inspectors spoke with all six people living at the home, staff, healthcare professionals and relatives. They observed care, checked care records, medicines, staff records and how the home was managed.
People were found to be safe and well supported. Staff understood people's needs, preferences and communication methods. Medicines were stored safely and given as prescribed. People were supported with healthcare, food, activities, independence, privacy and dignity.
The inspectors found a few issues. A fire extinguisher was not immediately available in the smoking area. One incident had not been referred promptly to the local investigating authority, although this was corrected during the inspection. Relatives had different views about the support from the registered manager.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found the service met the expected standards at the time of this inspection, but it was not rated Outstanding.
Kind and respectful staff
Inspectors saw warm and friendly relationships between staff and people. Staff knew people well and supported their privacy, dignity and choices.
“We observed warm and kind interactions between people and staff.” from the report
Personalised support
Care records included detailed information about people's needs, preferences, communication, health and social lives. People and relatives were involved in planning and reviewing support.
“People and their relatives remained involved in planning the support people required to meet their needs.” from the report
Good health support
Staff worked with specialist epilepsy services and other healthcare professionals. The improved alarm system helped staff respond more quickly when people needed help.
“The current system enabled staff to detect seizures more quickly, warn staff a person had fallen out of bed and was used by people to call for help when needed.” from the report
Activities and independence
People were supported to take part in activities, outings and social events. Staff encouraged people to manage parts of their personal care, meals and drinks where they could.
“Staff supported people to clean and tidy their rooms and to participate in the preparation of meals and drinks.” from the report
Fire equipment
seriousA fire extinguisher was not immediately available in the designated smoking area. The registered manager said this would be addressed after the inspection.
“We noted that a fire extinguisher was not immediately to hand in case of a fire emergency in the designated smoking area used by one person.” from the report
Safeguarding referral delay
seriousAn incident between two people had been recorded and reported internally, but it was not initially referred to the local investigating authority. The referral was made during the inspection.
“The registered manager took immediate action to refer the incident during this inspection.” from the report
Management capacity
needs fixingThe registered manager was responsible for this home and two other services. Relatives had differing views about the support they received from the registered manager.
“At the time of this inspection the registered manager had additional management responsibility for two of the provider's other services which meant their time during their working week was split across three different locations.” from the report
Communal lounge
minorOne relative felt the communal lounge was too small for everyone and that the seating was uncomfortable. The manager said the space was being used differently and new sofas had been bought.
“One told us that the communal lounge did not feel big enough to accommodate all the people using the service and the seating was uncomfortable.” from the report
- 01Has the fire extinguisher been placed in the designated smoking area, and how is fire safety checked now?
- 02What was the outcome of the safeguarding referral made during the inspection?
- 03How often is the registered manager at this home, given responsibility for three services?
- 04How does the acting deputy manager support the home day to day?
- 05Are the communal lounge space and seating now suitable for all the people living here?
This was an unannounced inspection covering all five key questions and the overall rating; inspectors spoke with all six people living at the home, staff, healthcare professionals and relatives. This explanation was written from the published report of 29 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Brambledown Road
3 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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