Bramshott Grange

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• 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 assessed a total of 5 quality statements in the well-led key question. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. At this assessment our rating for this key question has deteriorated to requires improvement. We identified the provider was in breach of 1 regulation and the provider had failed to ensure the always operated good governance. Examples of shortfalls included medicines processes and records, failure to provide all required notifiable information to CQC and shortfalls in staff training oversight. Staff told us there was a good culture across the staff team and they were able to seek support from leaders and peers. Staff understood how to speak up and raise any concerns and felt actions would be taken where required. Leaders of the service were visible and compassionate, and the provider engaged staff to promote their values and ethos.

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.

Staff provided positive feedback about the working culture and told us they were happy working at Bramshott Grange. One staff member said, “We are very kind to each other. We always want to learn something new.”

The provider used staff induction engagement to promote and embed their vision and values. The provider had appropriate policies in place to outline approaches that support people’s human rights. The provider ensured there were opportunities in place for people using the service, relatives and staff to engage regularly and meetings were used to share changes and share initiatives for the service. A relative confirmed this and said, “I do go to relatives’ meetings where people can air their views, but there really isn’t much to raise.”

Staff understood their role and the role and responsibilities of others. Staff liked and respected the manager. The leadership team were clearly visible in the service and accessible. Overall staff felt the registered manager acted upon feedback.

The provider had processes in place to support succession planning and encouraged staff to develop in their roles. The provider had processes in place to support them to embed their aims and commitments to people using the service, visitors and staff. This included staff recognition events and awards throughout the year.

Staff spoken with told us they felt able to speak out and they were aware of the relevant policies to support this. Overall staff felt any feedback raised would be acted on by leaders and good communication supported this.

There are established processes for people and staff to provide feedback which are understood. We shared feedback with the provider where the whistleblowing policy did not contain the correct local authority safeguarding contacts for staff to follow. Following our feedback the provider updated the policy to ensure the contents reflected the correct information. We reviewed staff engagement records such as team meeting minutes and clinical meeting minutes which demonstrated staff were given opportunities to share any concerns they wished to raise and relevant actions were taken.

Staff told us the team were culturally diverse. Overall staff felt well supported in their role and with their training needs and development. Staff felt leaders were accommodating to their individual needs and one staff told us leaders supported them to tailor their induction programme to better meet their needs.

The provider had a range of schemes in place to support staff in their role and with their development. The provider maintained oversight of staff retention rates across the organisation and actively explored schemes and incentives to retain staff and support their well-being. This included schemes such as staff larder food bank and financial support schemes if these were needed.

In discussions with leaders, we were not assured they always fully understood their legal requirements in relation to notifiable information they are required to share with CQC. Leaders understood their responsibilities to share safeguarding information with the relevant local authority, however leaders were not always clear when this information was also required to be shared with CQC. This included information where medicines errors had occurred and where there had been an altercation between people living at the service. Leaders told they completed a range of audits on a monthly basis. They told us actions were then consolidated into an action plan. Where we have identified some shortfalls in processes leaders of the service have been open and receptive to our feedback.

We were not assured the provider always operated effective systems and processes to oversee all areas of service delivery to identify and drive improvement. The provider had a range of audits and systems in place which included monthly safeguarding audits, review of accidents and incidents, people's records, weights, resident of the day and clinical meetings to review outcomes from records on a regular basis. However, we identified multiple shortfalls at this assessment in the providers medicines systems, and processes in place did not ensure staff practice and medicines related tasks were always in-line with best practice guidance. We also found some examples where people’s care records were not accurate or consistent. This included some people’s medicines records, MCA assessments and care plans and risk assessments where people had experienced a change in need. We reviewed staff training data and found systems in place to monitor staff training requirements was not effective to ensure all staff received and maintained up to date training in relevant areas related to their role. This included training requirements to meet people’s specific needs such as epilepsy, IDDSI and skin integrity training. The providers oversight of notifiable information was not robust. We identified 6 examples where relevant notifiable information had not been shared with CQC as legally required. Systems in place to review policies were not effective in identifying the shortfalls we found in the providers whistleblowing and safeguarding policy to ensure correct information was available to staff. We discussed where the content of some audits could be more robust to ensure detail was captured on what was reviewed or what actions had been taken. This included the complaints audit, dignity audit and audits where feedback had been provided that required some follow up actions.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.