Updated 10 February 2025
Date of Assessment: 13 and 14 February 2025. The service is a care home providing support to older people , including those living with dementia. There were 30 residents at the time of the assessment. This assessment was carried out because of concerns we had received about the management of a safeguarding concern in the service. We found a breach of the legal regulation in relation to good governance.
Governance systems had not ensured the provider maintained effective oversight of the service or took prompt action to make improvements. Environmental checks had repeatedly identified faults with fire safety systems but action had not been taken in a timely way to ensure people’s safety. Actions needed to ensure safe management of medicines had not been completed 2 months after they had been identified. Water outlets assessed to be ‘unsatisfactory’ took 20 months to be rectified.
Management had not always shared concerns quickly and taken action to ensure people were safe. The new manager was working to ensure everyone understood their responsibilities and was clear of actions they needed to take to keep people safe.
The service had experienced instability in the management team, with 3 managers over the previous 6 months. Two of these managers had been removed by the provider. Leaders had developed a values statement for the service, setting out what people could expect when living at Bramley House. However, some staff were not aware of these values.
Staff felt supported to give feedback and they were treated equally, free from bullying or harassment. People with protected characteristics felt supported. The service worked with a range of other professionals to help make sure people received continuity in their care.
Work had started to identify the extent of the shortfalls in the service and plan improvements.
We have asked the provider for an action plan in response to the concerns found at this assessment.