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 assessment we rated this key question inadequate. At this assessment the rating has remained inadequate.
This meant although we saw some improvements, 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.

At our last assessment the service was in breach of legal regulation in relation to the management of hazards around the home. At this assessment improvements were found, and the provider was no longer in breach of this regulation. The provider remained in breach of legal regulations relating to the safe care and treatment of people living at the service and protecting people from the risks of abuse and neglect, as sufficient improvements had not been made in these areas.
 

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Although there was a system in place to monitor, review and analyse when things had gone wrong, the effectiveness of this system was inconsistent. Some records of incidents such as falls were not sufficiently detailed. This made it difficult for staff to learn from incidents and plan to reduce risk in the future. For example, a person who was at risk of falls had a sensor in place to alert staff to their movements. When the person had an unwitnessed fall, the record of the fall did not mention whether the sensor was in use and activated or not. This record was checked by the registered manager who did not notice this detail was missing. This made it difficult for the team to review whether staff were using the sensor correctly. It also made it difficult to determine whether the sensor was actually helping the person to reduce risk of falls. We did see evidence of changes being made to people’s care and treatment as a result of reviews of incidents and learning from them. However, it was not consistent. This meant there was a risk of lessons learned being missed or delayed.

Analysis of falls lacked sufficient and important detail to identify themes and trends around risks to people. We saw no evidence the effectiveness of some interventions to reduce falls was checked. The registered manager was unable to demonstrate that systems to learn from falls had reduced the risks to people. We also saw no evidence of individualised falls analysis for people at higher risk of falls.

People and relatives told us they knew how to make complaints if they were unhappy. We did not see any clear guidance for people around the home about how to raise a complaint or share feedback with the management team. The registered manager told us no complaints had been received in the last 12 months at the service. There was a system in place to review and respond to any complaints raised. There was some confusion on the part of people and relatives over who in the management team should be spoken to in the event of a person or their relative having a concern. We saw no evidence of this preventing people from raising concerns. However, easily accessible guidance would have been beneficial.

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. We found there had been delays in staff seeking necessary medical intervention and care for some people after a fall. For example, 1 person waited at least 7 hours for paramedics to be called after they had sustained a fall which resulted in a broken bone. We also found there was no clear guidance for staff on how to monitor for signs of health deterioration. Some staff had been trained to take basic clinical observations to help monitor people’s health. However, there was no clear consistent process for when these checks would be used. The registered manager told us if a medical professional told them these checks needed to be implemented, they would do so. The checks were not consistently used to help staff decide when to share concerns about people with medical professionals. This meant there could be delays in people receiving the care and support needed from health professionals.

Documents called hospital passports were in place to share with other medical professionals to help them understand people’s needs quickly. One example we checked had not been updated with significant changes in a person’s mobility. The registered manager told us this was an out-of-date hospital passport which should have been archived. Since it had not, there was a risk hospital staff could assume the person could walk, when they needed assistance to mobilise.

We spoke with a medical professional who worked regularly with the service. They told us they considered the team to be generally proactive. They told us the staff followed directions from them well.

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.

We saw 1 example of allegations made about a staff member’s conduct toward a person living at the home were not shared correctly or fully with the local authority safeguarding team. Systems to review the safeguarding concerns shared with the local authority had not highlighted the information relayed had been factually inaccurate. Additionally, the safeguarding team had later been told, incorrectly, the safeguarding concern had been due to a ‘misunderstanding’. This was also not accurate and resulted in the safeguarding team not reviewing the allegations themselves.

We did see other examples of safeguarding concerns being identified, shared with partnership agencies and investigated appropriately.

The management team did not have a good understanding of their responsibilities under the Deprivation of Liberty Safeguards (DoLS). We found some people living at Bryony House did not have the mental capacity to consent to their care and that their care arrangements may have amounted to a deprivation of their liberty. The provider had not considered the need to apply for DoLS authorisations for these people, to ensure they were not being deprived of their liberty unlawfully. After discussing this with the provider, they took steps to apply for DoLS authorisations for people who needed them.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

We found risk assessments for some people’s current health conditions lacked detail and guidance for staff. This meant there was a risk staff would not be able to identify early signs of deterioration in these conditions. Although some staff had worked at the care home for many years and knew people well, sometimes the home was supported by agency staff who knew people less well. The registered manager explained staff did receive online training to help them learn about some of these health conditions. However, care documentation lacked clear information and guidance for staff on their role in monitoring and helping to manage individuals’ health needs. We did not see information, for example, about how well managed the health conditions were by current treatment and medication. For some health conditions there can be early warning signs of, or possible triggers for deterioration. These concerns were raised at our last inspection and had not been fully addressed by the provider. By the end of the assessment the registered manager shared with us updated care documentation, which was personalised, to a greater extent, to individuals’ care needs.

There was a failure to ensure information about people’s falls was recorded in enough detail to inform effective analysis. This meant there was a risk of people not receiving support to reduce their risks of falls in an effective and timely way.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We saw significant improvements in how the safety of the home environment was monitored. We saw appropriate window restrictors were in place to reduce the risk of falls from windows. We saw risk assessments were in place to help staff monitor the risks to people from access to the stairs. We saw products which could cause harm to people were stored safely.

However, people’s personal emergency evacuation plans (PEEPS) were only present in their electronic care files and were not presented in a summary format. This would make using them difficult for emergency services. The registered manager confirmed PEEPS had been printed out and a summary of people’s needs in the event of an emergency had been generated after we raised this. Overall, we found fire safety preparations were good. Staff we spoke with told us they had received training and participated in drills to ensure they understood what to do in the event of an emergency. Regular checks of equipment and facilities around the home ensured they remained safe for people to use.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective training and guidance, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There were no systems in place to ensure staff remained safe to perform the roles given to them. Staff received a Disclosure and Barring Service (DBS) check at the point of recruitment. DBS checks screen staff for their criminal record if they are working with children or vulnerable adults. However, following these no further DBS checks were conducted on staff, some of whom had worked at the service for over 20 years, to confirm they remained suitable to work with people. This meant people were at risk of receiving unsafe care from staff with undisclosed criminal records. The registered manager told us they planned to discuss possible steps to address this with the trustees of the service but had not yet done so.

Although there was e-learning in place to inform staff about the appropriate use of DoLS and mental capacity assessments, we found it was not effective. We found the provider had not consistently requested standard DoLS authorisations, in line with their responsibilities, and that mental capacity assessment were not decision specific. This demonstrated the ineffectiveness of the training provided. The management team told us they had found training they had personally completed in this area confusing.

Staff were not receiving training in line with the Oliver McGowan mandatory training requirement. This meant there was a risk to anyone with a learning disability living at the home of not receiving care and treatment tailored to their specific needs. The registered manager told us they had taken steps with their training provider to make sure this would be provided to staff.

Staff told us they received regular supervision. Some staff told us when staff called in sick, replacement staff were not always provided, to maintain staffing levels, which they found difficult. People living at the home told us they felt there were enough staff, although sometimes they seemed very busy and may not have a lot of time. Overall, relatives we spoke with told us they felt there were sufficient staff to provide safe care. One relative told us they sometimes found it harder to find a staff member when they needed one at weekends. During our site visits we saw people supported by adequate numbers of staff. There were times when the team were very busy, but it was never difficult to find a staff member when needed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Whilst, overall, we found the home to be clean and uncluttered, we did find some unaddressed infection prevention risks.

Two people’s bedroom carpets were stained and there was a strong odour in their rooms. When we highlighted these, the staff team responded straight away to address this.

During medication administration, we also observed a staff member putting tablets directly in a person’s mouth, with their hands, and handling other people’s medicines without sanitising their hands. The staff member acknowledged they should have made sure they had access to hand sanitiser before starting the medicines round.

Overall, the provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. However, we did find a controlled drug stock count was not correct for 1 medicine, and that the medication had gone out of date a few months earlier. Although there were systems in place to check stock counts and the dates by which medicines should be used, they had not identified these issues. This meant the management team could not be sure the person had been receiving the correct dose of their medication. It also meant there was a risk of them being given out of date and therefore potentially less effective medication. These issues were addressed as soon as they were highlighted to the management team.

Checks of staff competency to administer medications were being completed. However, we noted the checks did not record any assessment made of how infection prevention and control was promoted during medicines administration. One person had been assessed as needing covert medicines at the time of our assessment. Steps had been taken to ensure this was the safest and least restrictive option for them. People told us they were happy with the support they received to take their medicines. We saw guidance was available for staff when administering ‘as needed’ medicines. Records were kept ensuring people received support to have medicated creams applied as prescribed.