Bryony 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care, the physical environment, the safe management of medicines and keeping people safe from the risks of abuse.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. When people were involved in incidents or accidents, the management team did not always follow best practice. For example, when people had fallen, they did not consistently review the incidents to identify if something could be done differently to minimise the risk in the future. Care plans and risk assessments were not consistently reviewed to ensure people received consistent support from staff. The provider did not consistently review incidents to identify patterns or trends to help minimise the risks to people. Staff did not receive feedback on incidents, accidents or near miss incidents to help with their learning. However, despite our findings one relative concluded they believed the home was a “fairly safe environment,” for their family member to live in.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. Relatives provided differing experiences regarding the providers communication and engagement with partner agencies. Whilst some found the provider contacted healthcare partners quickly, others found they had to constantly ask for additional healthcare support or assessment for their family member. These relatives felt if had they not done so, their family member would not have received the assessment needed or this would have been avoidably delayed. Not everyone had a hospital passport. A hospital passport is a document that shares important information about a person’s health, communication needs, and personal preferences to help inform healthcare partners so the person receives joined up care. This lack of documentation could put people at risk of having consistent healthcare hampered by the lack of accurate information.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. One person told us about a concern they had. Staff were aware of this concern but had not passed it onto the relevant safeguarding authority. We found another concern where people were put at risk of abuse. The management team had failed to identify this incident and had failed to follow locally agreed procedures for identifying and reporting potential abuse.

We saw 2 staff acting inappropriately toward 1 person. When we informed a member of the management team they told us, “I have told them about their behaviour before.” However, this did not appear to be an effective strategy by the management team in preventing inappropriate behaviour or safeguarding people from bullying, harassment or abuse. However, despite our findings, relatives believed their family members were safe from abuse and ill treatment. One relative told us they felt their family member was safe at Bryony House.

People could not be assured their rights would be respected or promoted at Byrony House. We saw 1 person required covert medicines. This is where medicines were hidden in food or drink. We could not be assured the management team understood or followed best practice guidance for providing such medicines or had followed the Mental Capacity Act which directs how to support people who are unable to make decisions for themselves. These issues put people at the risk of having their rights not being upheld.

The service did not work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. One relative said, “[Relative’s name] has had a couple of falls and staff responded quickly. However, I don’t know if risks were looked at.” Another relative told us they thought their family member was safe but did not believe any risk assessments had been completed. The care plans we looked at did not consistently assess and record known risks to health and safety. People with known medical conditions did not always have assessments based on their specific needs. For example, when someone was living with diabetes, there was no care plan or risk assessment in place. There was no information for staff on what to do if the person experiences ill health because of their known condition. Risks associated with people’s mobility, skin diet or nutrition were not routinely assessed to inform staff on how to support to minimise risks. This put people at the risk of harm from inconsistent care and support.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care. We saw people had open access to potentially unsafe parts of the building. Hot water pipes leading to radiators were not always covered putting people at the risk of burns. Not all windows had restrictors putting people at the risk of falls from height, some handrails were lose putting people at the risk of falls, not all wardrobes were secured to a fixed-point putting people at the risk of crushing injuries and not all harmful cleaning products were safely locked away putting people at the risk of accidental or intentional ingestion. Access to the stairways had not been risk assessed to ensure people could safely access these areas of the home. These issues put people at the risk of avoidable harm.

The service did not always make sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development. One relative told us they had to go looking for staff, especially at weekends, as there didn’t seem to be many staff around. Especially if their relative needed assistance. Another relative said there is a core staff group who have been at Byrony House for quite a while, and they know their relative well. Others expressed some concern about recent changes in staffing numbers but did not feel their family member had been affected by these changes. Although staff had supervisions in place, their reactions and engagement with people was not effectively managed. A member of the management team told us they had attempted to address some staff behaviour, but this appeared to have little effect as we witnessed this behaviour was repeated during our inspection.

The provider followed safe recruitment processes when employing new staff.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We saw the extensive use of foam pipe lagging throughout the building. Whilst this lagging is effective in minimising the potential of burns, it is not easily cleaned. In a lot of instances throughout Byrony House, the lagging is secured with sticky tape which hinders effective cleaning. Additionally, there were compromised floor seals in communal bathrooms which hampered effective infection prevention and control measures.

The provider had commissioned a legionella risk assessment. Legionnaires' disease is a lung infection you can get from inhaling droplets of water. At the time of the inspection, the management team had not completed the immediate actions from this assessment to ensure people were safe. We saw there were dead leg pipes in the building. Dead leg pipes increased the risk of waterborne pathogens including, legionella, thereby increasing the health risk to people. Not all areas of the home were maintained in a way which safely supported effective infection prevention and control practices. Despite our findings, relatives found Bryony House to be clean and tidy and they felt staff followed safe practices when supporting their family members. This included the use of gloves and protective aprons.

People could not be assured they would receive their medicines or prescribed creams safely or as directed. We were told by the management team there was a protected medication round where the designated staff member would not be disturbed when supporting people with their medicines. However, we constantly saw this staff member answering and talking on the phone when supporting people with their medicines. They were interrupted by other staff members including other members of the management team. In 1 instance, they were taken away from supporting someone so they could not be assured the person had taken the medicine they had been prescribed. One person’s medicines had run out and they did not receive their prescribed medicine for a prolonged period of time. A homely remedy used for constipation and paracetamols had passed their expiry date by over 12 months which had not been identified by the management team. One person received paracetamols outside of the safe administration time period putting them at the risk of avoidable harm. Another person did not receive their paracetamol as a staff member had gone home with the medication keys. These issues put people at the risk of harm from poorly managed medicines.