Bramshott Grange

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• 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

We assessed a total of 4 quality statements in the safe key question. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Our rating for this key question has remained the same. We found areas of concern around the providers effectiveness to assess and monitor their medicines processes and some practices did not always reflect best practice guidance. We were not assured that people’s medicines records always contained adequate detail and directions for staff to follow were not always clear. These shortfalls constituted a breach in regulation as the provider failed to demonstrate good governance of medicines. We received positive feedback from people and their relatives that they felt they received safe care. Leaders of the service understood what actions they should take to keep people safe when things went wrong, which included sharing information with the relevant safeguarding authorities. The service adopted a proactive approach to learning and improvement and the provider promoted a positive learning culture. Individual risks to people were well managed and staff knew people and how to meet their needs safely. This included people’s mobility needs, falls risk management and where people required support with to use equipment.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People reported they could raise any concerns about safety and felt they would be listened to. They told us they felt the service was open. One person commented, “If there was something that was bothering me, I’d have a word, get up, and make noises.” and another person said, “My dear! I DO express an opinion all the time!” A relative said, “If I was concerned about anything at all, I wouldn’t hesitate to call, if it was a medicines problem I’d call the nursing station, if it was anything personal, I’d speak to [senior staff], and of course [The registered manager]. [The registered manager] is amazing, she’s a really fabulous person. But to be perfectly honest, [staff] will always contact me first if there was a worry of any kind, however small. The communication is excellent.” Another relative commented, “I have never needed to raise a complaint. I only ever have questions to do with my [loved one]. I always go straight to [The registered manager], she is wonderful, she always has time and takes things seriously. She is open, and never defensive, she will check and look into any concern.”

Staff told us how they reported any incidents on the provider's electronic record system. They told us these were then reviewed by the clinical staff to ensure the correct actions had been taken and to identify if any actions were required or had been completed. A staff member commented, “[Staff] have to learn from incidents, [Staff] are good here.”

There were processes in place to share learning across the provider's services. Leaders completed monthly audits and identified areas for improvement. This included audits for incidents and accidents. Leaders understood what to do when things went wrong, and we saw evidence that they applied their requirements under the Duty of Candour to be open and transparent with people and their families. We shared feedback that it was not always particularly clear on audits where the same colour had been used such as incident and falls audits to evaluate different metrics.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received positive feedback from people and their relatives that people felt they were safe in the home. Comments included, “I feel very safe here and there is absolutely nothing to complain about. I count myself very lucky to be here.” and, “Oh, [staff] are lovely here. I’m very happy.” One relative said, “[Loved one] is here because I know she’ll be looked and she’s safe.” Another told us, “Of the things that really matter, I have absolutely no concerns about [loved ones] safety whatsoever”.

Staff told us they received safeguarding training and understood what to report and who they could speak to. Staff told us they could discuss any concerns about people in the daily meeting. Leaders told us safeguarding was discussed with people at the residents and relatives’ meetings, and we reviewed minutes of the meetings which demonstrated this.

We made positive observations of people in their home. We observed people appeared relaxed in the company of staff and they knew the registered manager. We saw safeguarding information displayed for staff but not for people. We shared this feedback with the provider.

The provider’s safeguarding policy did not contain accurate and up to date information for the lead local authority and safeguarding leads for the service. We saw evidence that safeguarding concerns had been reported to the correct local authority, however the written policy for staff to follow was incorrect. This was raised with leaders of the service who took action to address this following our on-site visit. The provider had processes in place where people were identified as being deprived of their liberty and they made relevant applications to the authorising body where required. However, we identified shortfalls in mental capacity assessment’s (MCA) for some people. We found examples where staff completed people’s assessments for specific decisions such as living at the home and some information was conflicting, inaccurate or did not include the required information where care was being provided in a person’s best interest. We shared feedback with the provider that we found variability in the quality and content of some of the assessments and they told us they would review this.

Relatives we spoke with felt risks to their loved ones were discussed with them and well managed. They felt any required care and equipment was provided. They felt people's rights and freedoms were respected. Relatives had been made aware of the provider’s use of technology such as falls sensors that were in place to support people’s falls management. One relative commented, “[Loved one] has a fall motion mat now, which seems to work brilliantly.” Another relative told us, “They seem to have a good balance between independence and risk.” A person living at the service commented, “I am treated with dignity and kindness by everyone and risks about my condition have been explained to me clearly.”

Staff we spoke with had a good knowledge of risks to people and how they were managed. They felt relevant equipment, training and guidance was in place. The provider had introduced sensor equipment and technology to keep people safe following consultation as it was felt to be a less intrusive and less restrictive way of monitoring the risk to people from falling in their bedroom.

We observed there were processes in place to keep people safe. For example, where people were identified as being at risk from falls, they had their bed lowered and crash mats in place. Only 1 person had bed rails which can be restrictive. Technology was used to keep people safe from falls. During our on-site visit we observed staff managed a situation well where a person’s mood changed rapidly, and they were supported to go to a quiet area.

The provider used a range of tools on the electronic care system to screen and assess potential risks to people, both system-based tools and nationally recognised tools. People's daily care notes documented the care provided and whether the person declined to receive their care. Records documented where people chose not to follow professionals’ advice and people’s professional guidance such as any prescribed modified diets were recorded. We saw evidence that external professionals were involved where required to manage risks to people.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Overall, people we spoke with told us they received their medicines on time and were told why they needed them. One person said, “I am very clear about the medicines I’m taking, and I have access to good doctors and nurses through the staff.” Another person said, “My meds are all okay. I don’t take much. [Staff] tell me and explain all about them.” Only one person felt aspects of communication in this area could be improved.

From discussions with staff and leaders we were not always assured that best practice guidance was followed. For example, staff administering creams when delivering personal care for 3 people showed us where people’s creams were stored. They also showed and explained how the administration of creams was recorded via the task function of the provider’s care record system. They described how the regular and when required application of creams was recorded. Whilst reviewing these records we noted examples where the main entry described 'cream applied' and entries by staff did not always then clarify the name of the topical application that had been used. Therefore, we were not assured people’s creaming records as part of their personal care contained sufficient information. Leaders also confirmed care staff administering some prescribed topical creams such as emollients informed nursing staff when this had been applied, and nursing staff then completed the persons electronic medicines records. We discussed with leaders that this practice was not in line with national guidance and leaders told us they would review this. Staff explained how they ensured critical medicines were administered within 30 minutes of the prescribed times. We reviewed 3 people’s medicines records where they were prescribed time sensitive medications. We found these medicines had been administered within the correct time window, which confirmed improvements had been made compared to a previous review undertaken by healthcare professionals from the Integrated Care Board (ICB).

We identified shortfalls in medicines processes and were not assured records were always accurate, complete or contemporaneous. For example, staff were only recording the current temperatures for the medicine fridges. This meant we could not be assured that medicines requiring refrigeration were stored within their recommended temperature range. Where people’s medicines directions were generated by the GP or pharmacy, the providers auditing system failed to identify discrepancies or inconsistencies in directions for staff to follow. We found multiple examples where people's medicines directions were ambiguous or unclear which included directions for people’s eye drops, inhalers, and pain relief. We also found additional information to support staff administer variable dose and when required (PRN) medicines were not always personalised or in sufficient detail. This included records for people’s PRN pain relief, PRN laxatives, and epilepsy medicine. We reviewed 6 people’s personal emergency evacuation plans and found the required medicines section had not been completed for 2 people. This meant staff would not have the required information about people’s medicines and risks they may need to consider in the event of an emergency such as fire. Medicines were stored securely, and in-use expiry dates had been added to most medicines. However, the service had not identified that medicine dispensed by their preferred community pharmacy retained the manufacturers expiry date rather than an in-use expiry date based on the date of opening.