Bramcote Hills Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. We identified two breaches of the legal regulation to this key question.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and management were committed to work towards the providers shared direction of improvements. However, we found staff were not always aware of what improvements were required to be made and how they would be achieving the providers shared direction.

The provider had a shared direction with the management team. An action plan was in place to improve the service. Some actions had been completed and others were still incomplete with the management team working through them. However, this needed further improvement to include a process for people, relatives and staff to be involved to ensure their shared direction and culture can be achieved.

Staff told us the new management team were capable, compassionate and inclusive leaders. They told us the management were approachable, listened and were confident appropriate action would be taken. However, people living at the service were not always aware who the management and leadership team were because changes had not always been communicated.

Management changes had taken place since our last visit. However, there was not a system and process in place to ensure this was communicated to people living at Bramcote Hills to ensure people knew about the changes and who the new management team were. The management team acknowledged they had not always identified the shortfalls we had identified during our onsite visit. The new management team had been working with staff to include them in any changes and had made some changes to ensure people were safe. However, further work was needed as the manager had not identified the concerns of this assessment within their own processes and oversight. When concerns were raised the new manager understood the risks and told us what action they would be taking. The provider had been working with the local authority contracts team and had taken advice from an independent consultant to drive improvements around the safety and quality of the service.

Staff felt more comfortable with speaking up to the new manager and deputy manager and told us they were approachable and would listen without being blamed. Staff told us since the last CQC visit, the operations manager was more visible and if needed would speak up to them. The operations manager told us that the staff feedback regarding being unable to speak up at our last visit was right and since then they have explained to staff that they can speak up without being threatened with any negative impact.

The provider had made changes to the management team since our last visit. The new management team were more approachable and visible within the home. However, we found there were not systems and processes to ensure all feedback was recorded and investigated with clear information on what actions had been taken. The new manager was working towards making further improvements.

The management team told us they had been working hard to improve the culture within the home. A new role of staffing had been introduced called shift leaders to involve staff more with the decision making and give them more responsibility with running of shifts. Staff told us they felt they were treated fairly and were happier since extra staff had been employed.

We found some improvements had been made to engage and involve staff. However, the provider had failed to empower staff to contribute in positive change to shape the home to be a more equitable and inclusive organisation. The staff team meetings did not allow staff an opportunity to contribute to continually reviewing and improving the culture of the organisation in the context of equality, diversity and inclusion.

The new manager told us they are supported by the operational management team. The manager had come from one of their sister homes and told us they were working towards putting in similar systems and processes into Bramcote Hills Care Home because they worked well. A deputy manager also was supporting the service from a sister home. However, the management team could not demonstrate what the long-term plans were with regards to the management structure and their roles and responsibilities. We found there had been a lack of effective clinical governance across the home, and this has resulted in systematic issues with risk management and health conditions. This placed people at risk of harm. Lack of effective oversight had led to gaps and inaccuracies in care records. For example, we found food and fluid intake was not always recorded accurately. There was also a lack of specific and reflective care plans for diabetes, mental capacity, health conditions and risk management.

There was not a CQC registered manager in post at the time of our assessment. The new manager told us they were in the process of registering with the CQC. The management team continued to fail to put monitoring systems in place to ensure that there was an effective oversight of the service in relation to care planning, daily recording, risk management and safe medicine management. This meant the provider had failed to ensure they had identified risks, concerns and had not improved the care provided.

The staff team and management team could not explain what processes or systems were in place for learning and improving. Staff told us they were not provided with one-to-one supervision to reflect on any learning opportunities and improving. The manager told us they had moved care plans onto an electronic system. However, the care plans had not been completed and staff were not provided with adequate devices to access and update the electronic system. The manager changed their mind and told us they were still using paper-based records with the plan to move over to electronic system.

The provider did not have a system or process for people, staff, relatives, and visitors to be involved in developing the service. No engagement was made to involve people in obtaining their feedback to improve and develop the service. The provider had not ensured there was a culture of continuous learning and improving care. For example, staff were not given an opportunity to have supervisions. Supervisions and staff meetings provide staff members with an opportunity to reflect and learn from their practice, check competence, identify training needs and discuss concerns.