CQC report explained · a residential care home
What the CQC found at Sursum Limited Bramley House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2019
Sursum Limited Bramley House was rated Good; inspectors found safe, kind and personalised care, with clear improvements since the previous inspection.
This was a planned inspection because the previous rating was Requires Improvement. One inspector visited on 2 July 2019. The first day was unannounced. Inspectors spoke with people, relatives, staff and visiting professionals, and checked care, medicines, staff records and management systems.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines management, reviewed risk assessments, detailed care plans and regular checks on quality.
The home had improved since the previous inspection. The earlier breach about consent for people who lacked capacity had been put right. Earlier recommendations about medicines storage and care planning had also been addressed.
The overall Good rating means inspectors found a service that met people's needs consistently at the time of the inspection. The report also says CQC would continue monitoring information received about the home and could inspect sooner if concerns arose.
Safer medicines
Medicines were administered, managed and stored safely. A new electronic system helped staff identify missed medicines and stock issues.
“People's medicines were managed, administered and stored safely.” from the report
Personalised care
Care plans included people's preferences and full life histories. This helped staff understand people as individuals and respond to changing needs.
“Care plans were detailed and person centred with full life histories.” from the report
Kind and respectful staff
Inspectors saw gentle interactions and people being given time, choices and privacy. Relatives also described staff as kind and cheerful.
“We saw gentle interactions and instructions given, staff did not rush people.” from the report
Improved leadership
Management systems had become more reliable, with regular audits and clear responsibilities. Staff reported good support from the management team.
“The service had improved under the new registered manager.” from the report
Activities and relationships
The activities team offered different options for people's interests and abilities, including time outdoors, entertainment and one-to-one support.
“The service had a dedicated activities team who planned and undertook various forms of interests and entertainment according to people's preference and ability.” from the report
Complaints procedure under review
minorThe complaints policy and procedure was being reviewed and updated during the inspection. The report says complaints in the previous year had been resolved within 28 days.
“The home had a complaints policy and procedure in place which was being reviewed and updated at the time of the inspection.” from the report
- 01How do you now check that medicines are recorded correctly and that missed doses or stock problems are dealt with promptly?
- 02How do you decide staffing levels for each shift, including the evening comfort shift?
- 03How often are care plans and risk assessments reviewed, and how are changes in a person's needs recorded?
- 04Has the complaints policy review been completed, and how are current complaints investigated and resolved?
- 05What end-of-life support is available now, including the sitting service and advance care planning?
This was a planned inspection covering all five CQC questions, with the first day unannounced; the report checked the care provided, the premises, records, staff arrangements and management systems. This explanation was written from the published report of 24 August 2019 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, July 2018
Rated Requires Improvement; inspectors found kind, respectful care, but concerns about staffing, medicines, consent records and oversight.
This was a comprehensive inspection. It was unannounced on the first day. Inspectors observed care, spoke with people, relatives, managers and staff, and checked care plans, medicines records, staff files, training, complaints and quality checks.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good. Inspectors found a breach of the legal rules on consent because mental capacity assessments and best-interest decisions were not recorded for some people who lacked capacity.
There were also concerns about medicine storage and records, changing risks, staffing levels, staff training and supervision, and care plan reviews. The home had started improvements, including new audits and care planning systems, recruitment, extra training and air conditioning for the medicines room.
Kind and respectful care
People and relatives spoke positively about the staff. Inspectors saw staff being patient, friendly and respectful, including when supporting people with personal care.
“We observed that staff interacted with people in a kind and patient manner.” from the report
People felt safe
People said they felt safe. Staff knew how to recognise and report safeguarding concerns, and safeguarding procedures were available.
“People told us they felt safe living at Bramley House.” from the report
Activities and environment
The home had a range of activities, pets, communal areas and a level-access garden. People had helped choose plants and design parts of the garden.
“There was a range of activities available for people to participate in.” from the report
Medicines storage and records
seriousSome medicine records were incomplete or inconsistent. The medicines room was too warm on the inspection day and had also exceeded the recommended temperature on the previous five days.
“The temperature of the medicines room on the first floor was 26 degrees centigrade (on the day of our inspection).” from the report
Staffing levels
seriousPeople, relatives and staff reported that there were not always enough staff, particularly at busy times or when staff were off sick. Managers had identified the shortage and were recruiting.
“People and relatives told us that there were not always enough visible staff.” from the report
Risks were not always followed up
seriousRisk assessments were not reviewed regularly and did not always give clear instructions. Records of very low fluid intake did not show that concerns had been identified or escalated.
“The records did not show staff had identified the poor intake or whether they had escalated their concerns.” from the report
Consent records
seriousFor some people who lacked capacity, there were no mental capacity assessments or best-interest decisions to support applications for deprivation of liberty safeguards.
“There were no mental capacity assessments or best interest decision making documentation to accompany applications to authorise a Deprivation of Liberty Safeguard.” from the report
Care plans and changing needs
needs fixingCare plans were not always reviewed when people's needs changed. Some plans gave too little detail about anxiety, infections, personal care or how staff should support people.
“People's care plans were not always reviewed regularly to meet people's changing needs and the level of detail and guidance was inconsistent.” from the report
Training and supervision
needs fixingSome staff needed more up-to-date training, including in dementia care and behaviour that challenges. Staff did not consistently receive one-to-one meetings to discuss skills, support and development.
“Staff did not receive support from one to one discussions with their line manager to assess competencies, training needs and development and maintain well-being.” from the report
- 01What has changed to make sure medicines are stored at the correct temperature and all medicine entries are checked and signed?
- 02How many care staff are now on duty on mornings, evenings and nights, and what cover is provided when someone is off sick?
- 03How are mental capacity assessments and best-interest decisions now recorded before applications for deprivation of liberty safeguards?
- 04How often are risk assessments and care plans reviewed when a person's health, behaviour or daily needs change?
- 05What up-to-date training and one-to-one supervision have staff completed since this inspection?
This was a comprehensive inspection covering all five questions; the report says the previous inspection was in March 2016, when all required standards were being met. This explanation was written from the published report of 24 July 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 Sursum Limited Bramley House
3 rated inspections over 3 years: the service has held its Good rating throughout.
- August 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Sursum Limited Bramley House →
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Sursum Limited Bramley House →
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
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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