CQC report explained · a nursing home
What the CQC found at Bramley Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by care plans, risk assessments, safeguarding training and safely managed medicines. Inspectors did note that some staff were not using face masks in line with current guidance.
- Effective?
- Good
- People's needs and preferences were assessed and reflected in care plans. Staff had suitable training, supported people's dietary needs and worked with healthcare professionals.
- Caring?
- Good
- This question was not separately rated in the report. Inspectors observed staff seeking consent and supporting people to make choices.
- Responsive?
- Good
- This question was not separately rated in the report. Inspectors found a lack of support to help people with dementia find their bedrooms.
- Well-led?
- Good
- The home had systems to investigate incidents, monitor restraint and identify improvements. People, relatives and staff said the manager was approachable and they could share their views.
What inspectors found, July 2022
Rated Good; inspectors found safe, effective and well-led care, but noted some unsafe mask use and limited help for people with dementia to find their rooms.
This was an unannounced inspection on 15 and 17 June 2022. Inspectors spoke with five people, nine relatives and 14 staff. They reviewed care records, medicines records, recruitment files and the home's management records.
The home was rated Good overall. Safe, Effective and Well-led were all rated Good. Inspectors found suitable care plans and risk assessments, safely managed medicines, trained staff and systems for learning from incidents.
There were some shortfalls. Some staff were not using face masks in line with the latest guidance. People with dementia had limited help to recognise their bedrooms. The home had also made a medicine-related mistake, but inspectors found it had been corrected promptly.
The previous rating was Requires Improvement, published in January 2022. The home had previously breached Regulations 12 and 17. Inspectors found enough improvement had been made and the home was no longer in breach.
Clear risk planning
Care plans and risk assessments covered known risks and gave staff practical guidance. They were reviewed regularly.
“Clear care plans and risk assessments were in place for all people to guide staff.” from the report
Safe medicines
Medicine records were completed appropriately, staff were trained and checks of their competence were carried out.
“Medicine Administration Records (MAR) detailed people's prescribed medicines and were being appropriately completed in the home.” from the report
Staff training
Staff received regular training that matched people's needs, including dementia, wound care and moving and handling.
“People were cared for by a staff team who had received regular and appropriate training specific to their needs.” from the report
People's views included
People and relatives were involved through regular meetings, monthly updates and newsletters. Changes were made after people shared their views.
“Regular meetings were held with people living in the home giving people the opportunity to share their views.” from the report
Face mask use
needs fixingInspectors saw some staff using face masks incorrectly and not following the latest government guidance. The manager took immediate action after this was raised.
“We were not assured that the provider was always using personal protective equipment (PPE) effectively and safely.” from the report
Finding bedrooms
needs fixingThere were no photographs or personal memory items outside some rooms. This could make it harder for people with dementia to recognise their own bedrooms.
“There was a lack of photos or memorable items specific to the person outside of their rooms.” from the report
Medicine process error
minorInspectors reviewed a concern about a medicine process and found that a mistake had been made. The home took reasonable steps to correct it in good time.
“The registered manager was open and honest regarding a mistake that had been made.” from the report
- 01What steps have you taken to make sure all staff use face masks correctly?
- 02How do you help people with dementia recognise and find their bedrooms?
- 03What was the medicine mistake, and what checks now prevent a similar error?
- 04How do you review accidents, incidents and restraint to make improvements?
- 05How will you show that the improvements made since the Requires Improvement rating have been sustained?
This inspection rated Safe, Effective and Well-led; Caring and Responsive were not separately rated in the report. This explanation was written from the published report of 7 July 2022 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, January 2022
Bramley Court Care Home is rated Requires Improvement; inspectors found kind, personalised care but serious gaps in restraint training and COVID-19 risk management.
Inspectors visited without warning from 4 to 15 November 2021. They spoke with people, relatives and staff, observed care, and checked care plans, medicines, staff records and management systems.
The home was caring and responsive. People were treated kindly, their care plans reflected their needs, and they were supported with activities and contact with relatives. Relatives generally said people were safe and well cared for.
The home was not always safe, effective or well-led. Staff lacked specific training and guidance about low-level restraint, records did not show clearly when it was used, and COVID-19 risks and testing were not fully recorded or assessed. The overall rating fell from Good at the previous inspection under the former provider name to Requires Improvement.
Kind and respectful care
Inspectors saw staff who were polite, patient and respectful. Relatives described the care as very caring.
“[The staff] are very good, they are very very caring, it's not just a job it's a vocation and they really do care.” from the report
Personalised support
Care plans included people's backgrounds, health needs, communication preferences and desired outcomes. Staff encouraged people to make choices and remain independent.
“People's care plans were person centred and tailored to their needs.” from the report
Activities and family contact
People were supported to enjoy hobbies and events. During lockdown, the home used window visits, telephone calls and video calls to help people stay in touch.
“People were supported in a variety of ways to stay in contact with their loved ones during the pandemic.” from the report
Staffing and healthcare support
People and relatives said there were enough staff, and inspectors saw staff available in communal areas. Staff worked with healthcare professionals and followed their recommendations.
“Staff were visibly present in lounge and dining areas and were available to respond quickly to any requests from people.” from the report
Restraint training and records
seriousStaff had not received accredited training on low-level restraint. Records and care plans did not consistently explain when restraint was used or how it could be avoided, creating a risk of unnecessary or inconsistent restraint.
“Staff hadn't had specific training in the use of low-level restraint by a certified trainer.” from the report
COVID-19 risk management
seriousPeople did not have individual COVID-19 risk assessments. Staff lateral flow test results were not recorded and some staff risk assessments were not up to date.
“Care plans didn't contain individual COVID-19 risk assessments.” from the report
Weak management checks
seriousThe provider's quality systems did not identify the gaps in restraint practice and COVID-19 risk management. CQC found that oversight was not effective enough.
“The provider's governance systems were not always effective in identifying the need for improvement in assessing and mitigating risk.” from the report
Medicine list accuracy
minorSome homely remedies remained on medicine lists after they became regularly prescribed. Inspectors found no evidence that this had caused unsafe administration, but the manager agreed to review it.
“Homely remedies were not removed from medicine lists when they became prescribed regularly.” from the report
- 01What accredited training have staff now completed for low-level restraint, and who checks that it is used only when necessary and safely?
- 02How do you record, review and analyse every episode of low-level restraint, including what may have triggered it and how it could have been avoided?
- 03Have individual COVID-19 risk assessments now been completed for every person and relevant staff member?
- 04How are staff lateral flow test results recorded and checked now?
- 05What changes have you made to your quality checks so that risks in restraint practice, infection control and care records are identified promptly?
This was an unannounced inspection covering all five key questions, including infection prevention and control measures; it was the first inspection under the new provider name. This explanation was written from the published report of 25 January 2022 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 Bramley Court Care Home
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- June 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019
Registered with the Care Quality Commission on 2 September 2019.
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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