Broomgrove Trust Nursing 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 remained requires improvement. This meant 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 the last inspection the provider was found to be in breach of the legal regulation in relation to the deployment of sufficient numbers of skilled staff. Improvements were found at this inspection and the provider was no longer in breach of this regulation. However, some improvements were still required in relation to monitoring the effectiveness and quantity of staff deployed.

This service scored 59 (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. Lessons were not always learnt to continually identify and embed good practice. Analysis of incidents such as falls was evidenced in records. However, records also indicated that some risks to people had not been identified or acted upon. For example, people’s daily notes indicated that care was not always delivered in line with agreed plans of care in relation to people’s nutritional needs or skin integrity needs. Audits within the service had not identified these issues which had prevented staff and managers from learning form these incidents.

The provider did not always maintain safe systems of care. They did not always manage or monitor people’s safety. The provider did engage with health and social care professionals, for example with weekly GP visits. However, people’s plans of care sometimes contained contradictory information in relation to health needs. Daily records indicated that agreed actions required to keep people safe and well were not undertaken as often as needed, for example where people needed support to reposition themselves to maintain their skin integrity. The providers monitoring and auditing procedures had not identified or addressed these issues.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff had undertaken training in safeguarding as part of their mandatory training and knew how to raise a concern. Records of individual accidents and incidents were detailed and shared where appropriate.

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 in line with agreed plans of care. Feedback given by people and their relatives in relation to their involvement in risk management was mixed. Some people told us they had been consulted regarding their needs and involved in their care planning and felt staff knew them and their needs well. However, this feedback was inconsistent. Some people told us that information given to staff and managers regarding changes in people’s needs was not always acted upon. One relative told us, “My [relative’s] care plan is full of errors, some of which are medical, and the staff can’t edit it”, and, “As the care plan isn’t correct, bank staff don’t have the correct information.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had processes in place to ensure the safety of the home environment. This included regular maintenance checks of equipment such as hoists and slings, wheelchairs and mattresses. Water safety checks were undertaken regularly as were safety checks of the fire alarm system. It was noted that although window restrictors were in place to mitigate the risk of falls from height, checks on these were not routinely taking place. Information and advice was given to the provider who gave assurances that these would be incorporate into existing maintenance checks.

The provider did not always ensure that staff were delivering care that followed agreed plans of care. Although staff training was in place with a high percentage of staff undertaking all training, this had not resulted in all staff delivering care that met people’s needs. Recruitment was completed safely with suitable references sought and Disclosure and Barring Service (DBS) checks made before staff commenced employment. Some recruitment files showed unexplained gaps in peoples previous employment history, which is not in line current guidelines. The provider gave assurances that this would be amended, and future recruitment would include full employment histories. Feedback from staff, people and their relatives regarding staffing numbers were mixed. Some people told us at times the home seemed short of staff, but others felt that staffing numbers were appropriate. One relative told us, “There are enough staff to meet people’s needs, although there are less staff on a weekend, there’s always someone about.” However, a person told us, “I would say they need more (staff), they are always short and looking after 2 people at the same time.” Records showed that consistent levels of staff were deployed across a 7 day period. The provider used a dependency tool to analyse the needs of people to support decisions regarding staffing numbers. However, call bell audits, to analyse the length of time take to respond to people’s needs were not currently taking place and could not be assessed.

At the last inspection the provider was found to be in breach of the legal regulation in relation to the deployment of sufficient numbers of skilled staff. Improvements were found at this inspection and the provider was no longer in breach of this regulation. However, some improvements were still required in relation to monitoring the effectiveness and quantity of staff deployed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The environment was clean, and all staff had access to sufficient levels of personal protective equipment (PPE) such as gloves and aprons. Domestic staff were on duty 7 days a week to complete cleaning and laundry duties. Processes were in place to monitor the cleanliness of the environment.

Medicines were mainly managed safely. However, some improvements were required. Some creams and medicines that required dating once opened, to ensure they could be disposed of at the correct time were not dated. Information relating to the preparation of medicines to be administered covertly was not contained within the medicines administration file. Staff were observed thickening people’s drinks with a product that was previously prescribed to an individual that no longer needed this. Thickeners are prescribed items and should only be used for the individual named on the pharmacy label and are not intended as communal products.