Sursum Limited Bramley House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated safety events. Lessons were learnt to continually identify and embed good practice. The manager had established systems to record and review incidents to ensure actions were implemented. Learning from incidents was shared with all staff to ensure they understood changes in the way they needed to support people. Staff told us that since the change in management they were confident action would be taken to learn from any concerns they raised.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People told us the process of moving into the service worked well. People’s needs were assessed before they moved to Bramley House. This included liaising with the health and social care services people accessed.

The provider had not always shared safeguarding concerns quickly and appropriately. Concerns had been raised with the previous registered manager about the actions of a staff member, which had not been acted on to ensure people were safe. The concerns were also not shared with the local authority safeguarding team or the Care Quality Commission. Following this the provider made changes to the management of the service and a new manager had been in post for approximately 5 weeks at the time of our site visit. People told us they felt safe in the service. Staff had received training and demonstrated a good understanding of their safeguarding responsibilities. Staff told us that since the changes to the management of the service they felt confident any further concerns would be responded to appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Individual risks to people’s health, safety and welfare had been assessed and action taken to manage those risks. Staff demonstrated a good understanding of the risks and said plans were updated quickly when people’s needs changed. We observed staff supporting people in a safe way.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Checks were carried out on safety equipment in the service, but prompt action was not taken when defects were identified. Examples included the same defects in the emergency lighting systems were recorded each month between January 2024 and December 2024 and faults with some fire doors recorded on several occasions since July 2024. The manager told us weekly checks on the fire alarm system had not been completed. The provider had commissioned an external assessment of the fire safety systems in the service and was waiting for the report at the time of our site visit. A legionella risk assessment, completed in June 2023, identified 30 water outlets in the home which were assessed to be ‘unsatisfactory’. Action to address the risks was not recorded as having been completed until February 2025.

There were enough qualified, skilled and experienced staff, who received effective support. They worked together well to provide safe care that met people’s individual needs. People told us there were enough staff to meet their needs and staff had the right skills and knowledge to safely support them. Checks had been completed for staff before starting work, including a check with the Disclosure and Barring Service (DBS). However, the file for 1 member of staff did not contain any information about references from previous employers or an employment history. This information had been obtained by the second day of our site visit. New staff received an induction which included training and shadowing experienced staff. The manager had a record of training staff had completed and a system to plan when refresher courses were needed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of infections spreading and shared concerns with appropriate agencies promptly. People told us the service was always kept clean. We observed staff following good infection prevention and control practice, to help keep people safe. Staff said they had completed infection prevention and control training and had access to all the equipment they needed.

The provider did not always make sure that medicines were managed safely and met people’s needs and preferences. Staff did not always keep an accurate record of the medicines held in the service for people. The balance for 4 of the 7 of medicines we checked did not match what staff had recorded. Where people were prescribed medicines to be taken ‘as required’, there was not always clear information about when staff should support people to take them. For 2 people prescribed a sedative medicine to help with periods of distress, there was no information about when they should be supported to take it or other strategies staff should follow before administering the medicine. This increased the risk that people would be over sedated. Other records did not make clear that people would ask for their ‘as required’ medicines when they needed it.