The inspection took place on 13 and 14 November 2018. The inspection was unannounced.

Bramblings Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bramblings Residential Home provides accommodation and support for up to 42 older people. There were 36 people living at the service at the time of our inspection. People had varying care needs. Some people were living with dementia, some people had diabetes or had Parkinson’s disease, some people required support with their mobility around the home and others were able to walk around independently.

A registered manager was employed at the service. 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 our last inspection on 21 and 22 November 2017, the service was rated as ‘Requires Improvement’. We found breaches of Regulations 9, 11, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to, medicines administration processes were not managed safely; safe systems were not in place to identify and manage individual risks; robust recruitment processes were not used to make sure only suitable staff were employed; the basic principles of the Mental Capacity Act 2005 were not adhered to; effective system were not in operation to identify shortfalls in quality and safety; people’s needs and preferences were not met through the care planning and review system; Staff did not receive the appropriate training and supervision to carry out their role.

We took enforcement action against the provider and registered manager and told them they must meet Regulations 12 and 17 by 22 February 2018. At this inspection, improvements had been made to the management of people’s prescribed medicines, however the practices used when giving medicines to people were not safe. Risks to people’s safety were still not appropriately managed to prevent harm. Although accidents and incidents were suitably recorded, the management of falls continued to be a safety concern. Although some improvements had been made to quality monitoring, these were not robust enough to identify and sustain improvements.

The provider and registered manager sent an action plan dated 4 February 2018 stating they would meet Regulation 18 by May 2018 and Regulations 9, 11 and 19 by August 2018. At this inspection, the provider and registered manager had made improvements in some areas. Recruitment processes were now more robust, records showed safe practices were in place so only suitable staff were employed. Staff were now receiving the training and supervision support to carry out their role in providing care and support to people. However, the protection of people’s rights within the basic principles of the Mental Capacity Act 2005 continued to be an issue of concern. Time had been spent on a new care planning system, however, care plans did not capture and accurately record people’s specific and individual needs.

Although the provider and registered manager said they had enough staff to meet people’s needs, staff thought there were not enough to meet people’s social and emotional needs. Our observations showed this. We have made a recommendation about this.

Some people had their breakfast very late in the morning which meant they were not always able to eat their lunch, placing them at risk of not eating a healthy balanced diet. Their care plan did not record if it was their preference to get up late in the morning. This is an area we found needed improvement.

People’s en

The inspection took place on 21 and 22 November 2017. The inspection was unannounced on 21 November and announced on 22 November as we told the provider and registered manager when we would return.

Bramblings Residential Home is registered to provide accommodation and personal care without nursing for up to 42 people. There were 36 people living at the service at the time of our inspection.

People living in the service required care and support and had varying needs. Some people were living with dementia and some people had medical conditions such as diabetes or respiratory conditions and some people were recovering from suffering a stroke. Most people living in the service needed some support to move around. Some required the support of one staff member to move around whilst others required the support of two staff. Two people needed staff to support them to move by using a hoist. Some people were unwell and cared for in bed and others chose to remain in bed.

The service was set out over two floors with a passenger lift to take people between floors. The service was set in large grounds with pleasant gardens that people could sit out in when the weather was fine.

A registered manager was employed at the service. 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 last inspection report for Bramblings Residential Home was published on 13 December 2016 following a comprehensive inspection on 24 October 2016 when the service was rated requires improvement. Four breaches of legal requirements were found in relation to Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider and registered manager to take action to meet the regulations.

After the inspection, the provider sent us an action plan on 14 December 2016 which detailed how they planned to address the breaches of Regulations. They said they would be compliant by June 2017.

At this inspection, we found some improvements had been made to meet the regulations, however further improvement was required and the service continued to be in breach of regulations.

Some elements of how medicines administration was managed continued to need improvement. Prescribed thickeners to add to people’s drinks to prevent choking were not stored or administered safely. Anomalies were found in the numbers of medicines in stock when checked. Medicines audits did not highlight the concerns found.

Individual risk assessments were not in place to give the guidance necessary to staff when providing care to keep people safe and prevent harm. Infection control procedures were not robust as people shared the use of a hoist sling and personal toiletry products were left in communal bathrooms.

Fire prevention processes were not always evidenced to show robust systems were in place to keep people safe in the event of a fire on the premises. All servicing of systems and equipment had been carried out by the appropriate professionals.

Safe recruitment procedures were not followed to ensure only suitable staff were employed to provide care and support to people living in the service.

Staff did not always complete the training required to carry out their role. One to one staff supervision was not undertaken regularly or as described in the provider’s supervision procedure.

The basic principles of the Mental Capacity Act 2005 had not always been followed to ensure people’s rights were upheld. Deprivation of Liberty Safeguards applications had been made and the registered manager kept these under review.

People’s needs were not regularly assessed to ensure the appropriate care and support was being delivered. People’s needs had changed and c

This inspection took place on 24 October 2016 and was unannounced. Bramblings Residential Home is a 42 bed care home for older people that does not provide nursing care. There were 41 people living at the home at the time of this inspection. When we last inspected the service on 13 September 2013 the provider was meeting the required standards. At this inspection we found that the provider was not meeting the required standards.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Staff were knowledgeable about the risks associated with people`s daily living and routinely mitigated some of these identified risks. However there were very few risk assessments developed with management plans to offer guidance for staff in what steps were needed to mitigate the risks.

People who had a diagnosis of dementia or had a confused state of mind had no mental capacity assessments in place to establish if they had capacity to understand and take informed decisions regarding the care and support they received from staff. Best interest processes were not followed to ensure the care and support people received was in their best interest.

Where people had restrictions applied to their freedom in order to keep them safe, the registered manager has not applied for Deprivation of Liberty Authorisations (DoLS) to ensure they were depriving people of their liberty lawfully.

People had their medicines administered by trained staff; however they did not always receive their medicines as intended by the prescriber. Staff failed to ensure that people had their medicines available in sufficient quantities.

People had little opportunities to participate in activities or pursue their hobbies and interest. When activity staff were absent there were no alternative arrangements in place to ensure people were provided with an activity programme of interest to occupy their time.

People told us they were involved in decisions about their care, however, some people could not recall having been involved and their consent was not always accurately reflected in their individual plans of care. Care plans were not personalised to reflect people`s likes, dislikes and preferences about the care they received. These had not identified and detailed all the care needs people had and did not offer sufficient guidance for staff to understand and deliver care and support in a personalised way. People`s care plans were not always reflective of their current needs.

People who lived at the home were positive about the skills and abilities of the care staff. Staff received induction training when they started working at the home and yearly refresher training in key areas such as safeguarding, infection control, manual handling and first aid. However the registered manager could not evidence to us that agency staff working at the home received any training or if they were suitable to work and deliver care to people. Staff told us they had regular supervisions and felt supported by the home management team.

The quality assurance systems were not effective. The regular audits carried out by the registered manager and the provider were not comprehensive enough and had not identified all the issues and concerns we identified at this inspection. Care records were not up to date and not always reflective of people`s care needs.

People were cared for in a kind and compassionate way by staff who knew them well and were familiar with their individual needs, preferences and personal circumstances. We saw that staff had developed positive and caring relationships with people who lived at the home. They provided care and support in a respectful way promoting

This inspection was to follow up on the findings from our previous inspection of 18 June 2013 to assess if action had been taken with regards to the concerns we identified.

We found that the provider had taken action to address concerns around assessing and monitoring the quality of service that people received. We also found that appropriate action had been taken to ensure that people's care plans had been regularly reviewed in order to accurately reflect each individual's needs and that people's personal records were securely maintained.

People told us they "Liked" living in the home and that the staff were very "Caring" and "Attentive". One person said "I'm really happy here and get on with all of the staff" and another person said "I would never go anywhere else now". They told us they were happy with the care and support provided by the service and felt that the home was well run.

Our observations on the day showed that people were supported by staff in a way that promoted their dignity and independence. The atmosphere in the home seemed relaxed and staff were observed to be caring and supportive in their approach to people. They appeared to know them well and clearly understood their needs and preferences.

We found that the provider had addressed our previous concerns regarding staff training and supervision. Staff told us that they were able to access the required training in order to deliver safe and appropriate care to people who lived in the home.

We found that the service had completed the appropriate checks in order to maintain a safe and suitable environment for people but improvement is required with regards to monitoring and reviewing the care provided.

We found concerns that people's personal records were not always updated in order to accurately reflect their care needs and that personal information was not securely stored.

As part of our inspection we spoke with 5 people who used the service and their relatives about the care and support they received. We also spoke with the Registered Manager and 4 support staff. During the inspection we saw that staff interactions with people were positive and there was a friendly and relaxed atmosphere.

People spoke highly of the staff and told us they were happy with the care provided at the home. Comments included "I like it here", "People are well looked after" and "The staff are lovely and come quickly when you call them".

We found that people were encouraged to be as independent as possible, were supported to make choices and be involved in their care. People said that staff are "Friendly" and "Attentive" and if they had any concerns they knew who to speak with.

All of the people we spoke with said they liked the food and were involved in menu choices. One person told us "I've just had a nice big dinner and now I've got pudding" and "If I don't like what's on the menu then I can just ask for something else".

Relatives of people told us they were happy with the service and felt that people are safe. They told us that they had no problems or concerns. Comments included "I've never had any concerns here" and "I'm confident it's safe".

Staff told us they felt "Supported" by their manager. We found that many staff had not received up to date training and supervision which could affect the care and support that was provided.

We spoke with five people living at the home and a visitor, as well as three staff and the manager. All the people living at the home said that they were very happy and comments made included “the staff are excellent”. All the people spoken with also said the food was very good. People said they were well cared for and had everything they needed. One person had been living at the home for around 4 weeks and was still settling in. Despite being sad to leave her own home she said that the staff had made her feel very welcome and that “nothing is too much trouble for them”. Another person spoken with commented “I would recommend anyone to come here”.

People said that they enjoyed the activities at the home and that they could take part in anything going on. People said there was a friendly atmosphere and that they had never had any cause to complain.