Bramble Down is a care home providing nursing care to up to 40 people. Most but not all of the people living at the home are older people. The home does not offer care to people with dementia as a primary diagnosis but some people may have some memory loss associated with other illness or disability.

The home is set over two floors, with a lift to access the first floor. It is set in the small rural village of Denbury. Accommodation is offered to people in single or shared rooms.

At the last inspection in January 2015 the home was rated as good in all areas. At this inspection we found the home remained good.

Why the service is rated Good

The home was being well managed and run. It was well resourced, which helped ensure there were suitable numbers of well trained and skilled staff to meet people’s needs. Where equipment or specialist training was needed this had been provided. The registered manager and provider had put in place systems and audits to ensure high standards were maintained at all times, and regularly updated their practice and knowledge so they could confidently set and oversee standards at the home. Effective quality assurance systems were in place, where people were able to contribute their views about the service.

People received safe care in an environment that was regularly reviewed for risks and actions were taken to reduce these where identified. These included assessments of potential risks from fire, hot water and infection control.

Risks to people’s health or well-being were assessed and mitigated through a series of risk assessments and actions taken to control them. This included assessments of people’s mobility, moving and positioning, nutrition, and any pressure ulcer prevention. These were regularly updated and specialist advice sought when needed.

People received their medicines safely, and people were protected because staff understood how to identify and report concerns or abuse. Systems were in place for the management of complaints and concerns, although most people told us they would just tell the registered manager if they had any concerns and would be confident they would be addressed.

People received care from staff who had been subject to a robust recruitment process. Systems for staff training and support ensured staff received the training and support they needed to fulfil their job role. We saw and people told us that staff had built positive and valued relationships with people and supported them to be as independent as they were able. A relative told us they had placed great trust in the staff at the home, and felt confident leaving their relation at night knowing they would be well looked after.

People received a well-balanced and nutritious diet. Meals were home cooked and people told us they were tasty. Where people were at risk of poor nutrition the home had taken action to monitor their intake refer them to other agencies such as the GP or dieticians for support.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People‘s rights regarding capacity and consent were understood and supported.

People’s privacy and dignity was respected, and their independence was encouraged as far as people were able. This included recognition of activities people could do for themselves, including eating and moving, although this might take additional time. The home had policies that enabled relatives to continue to be involved with their relations care, including personal care if they wished. This was a comfort to people, especially at the end of their lives.

Relatives told us they were involved in making and supporting decisions about people’s care where they were not able to do so, and we saw people received individual care in accordance with their agreed care plan.

The home had a very full activities programme, offering a

There were 34 people living at Bramble Down at the time of our inspection. We spoke with eight people who lived at the home, the manager, two registered nurses, two visitors, four care staff, a cook, an activities coordinator and two visiting health care professionals.

Care and treatment was delivered in a way that was intended to ensure people's safety and welfare. There was no evidence to confirm that people were asked for their consent or how the provider acted in accordance with their wishes before they received any care or treatment.

People who live at the home told us they were well looked after and were happy. One person said "I am very happy here. I am really well looked after”. A family member told us “We were looking for a home where staff had compassion, and we have found it”.

People had been protected from unsafe or unsuitable equipment. This was because the provider had systems to ensure care staff were trained to use it and that regular servicing was carried out.

Records we looked at did not confirm that the provider gave serious consideration to recruitment decisions. We did not see that there was a robust recruitment procedure in place at Bramble Down to ensure suitable and properly qualified people had been employed by the home.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

People that we spoke with made positive comments about the way they were looked after. “I am very satisfied with the way I am looked after”, “I get all the help I need, but sometimes have to wait for staff to be available to help me”, “the staff are all so helpful and kind to me” and “I had a couple of trial stays here before coming to live here permanently. I am very happy here and would not want to live anywhere else”.

They told us “the food is always well cooked and nicely presented”, “I only like to eat fish and I am served different fish meals every day”, “we can have our meals served in the dining room or my bedroom” and “we always get fresh vegetables and home cooked meals”.

We found the home to be clean and tidy throughout and the management of medicines was generally all in order. If people wanted to make comments, raise concerns or complaints, that they would be listened to and appropriate action taken where possible.

We looked at the arrangements in place to support the staff team to do their jobs and found that staff were well trained and their work practice was supervised.

The people we spoke with at Bramble Down were positive about the care and treatment they or their relatives had received. The people that used the service said they felt they were involved in their care, had understood the treatment they were receiving and had been told about the options open to them. People told us that the staff were respectful and that they felt listened to.

We spoke to one person during our visit about the reason for their admission and the care provided to them. They told us that they understood both why they were living at the home and about the care they were receiving.

People told us that their privacy and dignity were respected and that they were encouraged to express preferences and choices about their care and treatment.

We spoke to seven people during our visit, some of whom were living at the home and others who were visiting. People we spoke to were generally complimentary about the service provided by the care home and told us “we are all cared for very well”, “Staff are so kind and look after us all” and “I wouldn’t want to be anywhere else, it’s lovely here”.

One person told us that the staff were friendly and caring and that they brought drinks and food to them regularly. Another person, who chose to mostly stay in their room, told us they saw staff regularly.

A relative told us that staff keep them informed of any changes in their relative’s health and involved them in planning how they were going to deliver care. They also said “This is a lovely little place. The girls are lovely and look after me as well. It’s nice to think you’re appreciated”.

The four members of staff we spoke with had a good knowledge of people's needs and told us how the service was meeting these needs.

On the day of our visit we found that the care home was clean and people confirmed to us that this was always the case. A relative also confirmed this and told us “if it wasn’t I would let them know”.

This inspection took place on the 13 and 16 January 2015, and was unannounced. The second visit made to complete the inspection on 16 January 2015 was by appointment.

Bramble Down is a care home with nursing, situated in the village of Denbury, approximately three miles from the market town of Newton Abbot. The home is registered to provide nursing care for up to 40 people, and was full at the time of our inspection. People who lived at the home were older people with general nursing needs. Some people had moved to the home for end of life care, while others were there for a period of recovery and rehabilitation before returning to their own home.

As a policy the home does not provide care for people with dementia as a primary diagnosis, although we saw some people who lived there had a mild degree of memory loss associated with other ill health.

On our last inspection of the home in February 2014 we had identified concerns in relation to the staff recruitment processes in place and the staff’s understanding and recording of people’s capacity to consent to their care. The provider sent us an action plan telling us that they would complete improvements to put these right by the 30th April 2014. On this inspection we saw that the improvements needed had been made and sustained.

The service had a registered manager in post. 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.

We saw that people were supported in a service that was safe. Risks to people’s health and safety were managed appropriately and people had opportunities to remain independent and take appropriate risks to enhance their quality of life. Staff understood people’s rights and how to protect them from potential abuse or harm.

We saw that fluid balance charts had not always been fully completed where people were at risk of poor hydration. This meant that it was not possible for nurses to accurately check how much fluid people had taken. This put people at potential risk of poor hydration, although we did not identify anyone who was poorly hydrated on the inspection.

There were enough staff on duty throughout the day and night to meet people’s needs. People we spoke with told us their needs were met, and we saw that although the home was busy people received individualised care in the way they wanted.

People were asked about how they wanted their care to be delivered, and we saw that care was delivered in accordance with people’s care plans and their wishes. Care staff were well organised so that it was clear each day who they were responsible for supporting. This helped to ensure that people’s care needs did not get missed.

We saw that staff had the skills, knowledge and training to help them meet people’s needs. Staff told us they received good support at the home and that it was a good place to work.

We saw that the home managed people’s medication well, including complex pain relief for end of life care. The home’s staff were proactive in supporting people’s healthcare, and account was taken of people’s recovery goals and aspirations wherever possible. We saw that people had access to good community healthcare support services such as community physiotherapy or end of life care nurses.

People told us they enjoyed the meals at the home, which were described as good wholesome cooking, using fresh and local produce wherever possible. We saw people who needed support to eat were given this sensitively and in ways that respected their dignity.

People’s capacity to consent to care was recorded, and where they could not do this records and assessments showed that decisions had been made in people’s best interests. People's communication needs were assessed. We saw that no-one who lived at the home was being deprived of their liberty.

We saw that the staff were caring, both helping people to celebrate positive events and offer support at times of distress. We saw that there were good relationships between people receiving care and those supporting them. Staff we spoke with told us they were proud of the home’s approach to end of life care which was based on good practice and positive links with local hospice services.

People had access to interesting activities that met their needs and wishes. We saw that the activities organiser had used innovative, creative and individual approaches to supporting people to remain active and involved where they were able to be.

We saw that care was individual and person centred. Staff we spoke with had a good understanding of the backgrounds, needs and wishes of the people they were caring for. They understood the importance of social, emotional and spiritual elements of people’s care as well as medical needs.

The service managed any complaints or concerns well. People told us they felt able to raise any issues and be confident of a resolution without recrimination. The culture at Bramble Down was open and the manager told us her door “is always open”.

We saw that the provider met legal obligations to the Care Quality Commission, and was operating in accordance with their conditions of registration. Quality assurance and audit systems in place ensured that people received a consistently good standard of service, and that learning took place to develop the service further.