Breckside Park Residential Home

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 requires improvement. At this assessment 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 safe care and treatment.

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 provider did not have a proactive and positive culture of safety based on openness and honesty. For example, events including accidents and incidents were not always reported in line with the providers policy and procedure. Those that were recorded lacked detail about the event such as the incident location, details of staff who recorded the incident and details of any immediate action taken to mitigate risk. There were no records maintained of an analysis completed following events to establish any lessons learnt and how they were shared with staff.

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. For example, one person’s care plan was not updated to reflect changes in their mobility following a recent discharge from hospital.

However, visiting professionals told us staff followed their advice and guidance.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. For example, there was ongoing concerns in relation to a person’s safety, however, the concerns were not referred onto the local authority safeguarding team for their review placing the person at risk of harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, there were multiple examples were people’s care records lacked information and guidance for staff on how to keep people safe. Records for 3 people did not provide clear guidance on how to mitigate a known risk to them and others. Airflow mattresses used by 2 people at risk of skin breakdown were unplugged and monitors connected to airflow mattresses for another 2 people were indicating a fault. The registered manager confirmed there were no systems in place to monitor the safety of airflow mattresses.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. For example, parts of the premises and equipment were unsafe. Bedrooms occupied by people who smoked in them were cluttered with flammable items and one person was using a plastic cup to dispose of their cigarette butts. An external fire exit on the ground floor was obstructed and another was in disrepair. There was a build-up of moss, weeds and rubble on the steps leading from the basement to the fire assembly point posing a slip, trip and fall hazard. The fire escape route was obstructed with discarded items including ladders, a broken toilet and plastic boxes.

The provider did not always make sure staff worked together well to provide safe care that met people’s individual needs. For example, we observed multiple occasions where staff teams did not follow safe practice to ensure people received safe care and treatment. Staff routinely used unclean equipment to assist people with their mobility. We observed examples were staff served people drinks without cleaning jugs and cups in between use.

However, there were sufficient numbers of staff on duty and they confirmed they received regular training and support.

The provider did not assess or manage the risk of infection. For example, parts of the home and equipment were unclean and unhygienic. Managers and staff had completed IPC training and had access to the providers IPC policy and procedures. Despite this they failed to apply their knowledge in practice to minimise the spread of infection. Walls, skirting boards and door thresholds were unclean across communal areas, corridors and people’s bedrooms. There was a build-up of food debris and spillages on dining and bedroom furniture. Equipment used to support people with their mobility was unclean and unhygienic. This included stand aids, wheelchairs, hoists, falls mats, sensor mats, commodes and walking aids. Staff did not always dispose of PPE safely; items of PPE were disposed of in domestic bins. Hand sanitiser units mounted on walls throughout the home were empty and dirty.

The provider did not always ensure medicines and treatments were stored and managed safely. For example, on 3 occasions throughout our site visit we observed the medication room door open and unattended. On 1 of those occasions the cabinets containing people’s medication was unlocked. The medicines room and medicine storage cabinets were cluttered and unclean with a build-up of dust and spillages. Non-clinical items including money was stored in cabinets alongside medicines. We found multiple prescribed creams and ointments located around the home including bedrooms and bathrooms, some which had expired in date and some with labels that were worn and unreadable. Medicines prescribed for 2 people did not tally with the records held and this error had not been identified or reported. Body maps were not used to guide staff on the application site for prescribed ointments and creams. Managers confirmed they had not implemented a system for using body maps.