Brockenhurst

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 good. 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 people’s safe care and treatment, management of environmental risks, staffing and administration of medicines.

This service scored 31 (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. They did not always listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems for monitoring people’s safety were not robust. Records of incidents were inconsistent, and there was a failure to investigate and learn lessons from incidents to improve safety.

One person was assessed as being at risk of falling out of bed and had bed rails in place. Staff had recorded incidents when the person had climbed over the bed rails and fallen. Following these incidents there was no investigation or review of the risks to determine if bed rails remained the safest and least restrictive option for this person.

Records showed people were having multiple falls but there was an inconsistent approach to investigating and reviewing their care needs. Staff had documented 7 falls for one person in a falls record for a two-month period and 2 additional falls were noted within their daily records. The provider had noted most falls were a result of slipping from a chair to the floor. However, records showed all the falls were unwitnessed and in different places, including the corridor near the bedroom, the small lounge, and the dining room, therefore, it was not clear how the falls occurred. The failure to properly investigate and review these incidents meant the person had continued to be exposed to risks of significant harm from falls.

Staff did not demonstrate an understanding of when to report incidents such as altercations between people. One staff member said, “We record it in the daily record and try and talk to the person, offer them a cup of tea.” Another staff member said, “We tell a senior, they record it.” We noted some events, including altercations between people, were recorded in their daily records but had not been reported as incidents. There was no record of what actions had been taken to evaluate these incidents, including escalating as safeguarding concerns to the local authority. This did not give assurance that all incidents were reported internally and externally, or that appropriate actions had been taken to identify safeguarding concerns and prevent further occurrences.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems for managing admissions to the service were not robust. An initial assessment of people’s needs lacked consistency. Risks to people’s health and safety were not always identified and assessed to ensure staff had the skills to meet people’s needs. On admission to the service a person was identified as being diabetic but a risk assessment and care plan was not put in place to guide staff in how to support the person with management of diabetes. There was no guidance for staff in what signs or symptoms might indicate a deterioration in their health due to diabetes and their nutritional and hydration care plan did not mention diabetes.

The provider did not have effective systems to review and make changes to care plans when people’s needs changed. This meant that staff did not always have the information they needed to provide safe and effective care. A person’s mental health need had increased due to a progression in their dementia. The care plan and risk assessment had not been reviewed and adjusted to provide staff with the guidance they needed to support the person’s increased needs. We observed how staff were supporting the person when they were showing signs of emotion and distress. Although staff were kind in their approach, they did not use clear strategies or techniques when supporting the person.

Daily records showed a person who was receiving care in bed had developed an open wound. A staff member described the system staff should follow for reporting changes to skin integrity. This included contacting the district nurse and recording the changes to care routine within the staff handover meeting to make staff aware. There was no care plan relating to pressure care or wound care and staff had not recorded what actions were taken to support the wound to heal. The staff member confirmed the wound had healed but there was no record of what actions had been taken or of the care and treatment provided in respect of this wound. There was no review of risks to skin integrity or changes to the care plan to reduce risks of further wounds developing.

Following feedback from the inspector regarding concerns about risk management, the provider told us they were seeking support from the local authority to arrange the transfer of care for some people. This did not support a planned and balanced approach to transitions and brought into question the provider’s systems for monitoring risks.

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 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 share concerns quickly and appropriately.

Systems for safeguarding people were not robust. One person told us they did not always feel safe. They explained other people sometimes came into their bedroom uninvited and they were worried about what might happen. Another person was heard to say they felt frightened when another person was distressed and shouting. The staff who were present did not offer reassurance or acknowledge their fear.

Records included altercations between people which had resulted in verbal abuse and physical harm. These events had not been considered by the provider as safeguarding incidents. This meant safeguarding alerts had not been raised with the local authority and the required notifications to the Care Quality Commission were not submitted.

The provider told us staff had recently completed training in safeguarding people. Some staff did not demonstrate a clear understanding of their responsibilities, including how to recognise signs of abuse, what to do or when to report concerns. One staff member told us it was about keeping people safe and described how they would look for trip hazards in people’s rooms. Another staff member said they would report any concerns to the deputy manager or the provider, but said they were not sure what current procedures and local arrangements were with regard to safeguarding people. This did not provide assurance that all staff had a clear understanding about safeguarding people.

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 safely.

Risks of falls were not being effectively assessed and managed. People were identified as being at risk of falls but there were not adequate measures in place to ensure their safety. One person had a history of falls and was assessed to be at high risk. The risk assessment did not include that the person was prescribed medicine that could significantly increase their risk of injury if they were to fall and there was no guidance for staff about this. There were no mitigating actions in place to reduce risks of falls for this person.

The provider told us that staff were mitigating risks of falls on the stairs by encouraging people to come down to the ground floor where staff could support them, including when they used the stairs. However, we observed people who were at risk of falls using the stairs independently without support from staff. Every care plan and risk assessment we saw relating to people at risk of falls identified the need to wear appropriate footwear as a mitigating factor to reduce risks of falls. However, we observed three people, who were independently accessing the stairs, were wearing poorly fitting footwear.

Another person was identified as having limited mobility. Their care plan included the need for support from staff when moving around. The provider had introduced an electronic sensor mat to alert staff when the person was moving from their chair. However, the sensor mat was currently not working as it was broken. There had been no alternative measures put in place to ensure the safety of the person whilst the sensor mat was out of use.

Risks associated with people’s health and care needs were not always assessed and managed. Some people were receiving care in bed due to a deterioration in their health. There was no risk assessment or care plan to provide guidance for staff in how to support a person to change position in the bed. There was no guidance about how to ensure they were in a safe position before offering food or drink. At mealtime we observed how one staff member supported a person to move in bed. They were not successful in supporting the person into a safe and comfortable position but continued to try and support them with food and drink. This put the person at risk of choking.

Some people were receiving a modified diet. The nutrition and hydration care plans did not include that they were having a modified diet or why. Staff who prepared the food did not know what level of modification was required or why. There were no risk assessments or care plans relating to risks of choking for these people. This meant the provider could not be assured that risks of choking were effectively assessed and managed or that people were receiving the correct level of modification for their needs.

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.

The provider told us they believed it was important for people to remain physically active for as long as possible and therefore people were able to access the stairs throughout the service to support their physical fitness. There was no risk assessment in place for use of the stairs and there were no restrictions in place to prevent people who were at risk of falls from accessing the stairs independently. The stair carpet was highly patterned, this was not suitable for people with dementia and could potentially increase their risk of falls. Guidance for dementia friendly environments includes that patterned carpets can impact spatial awareness, visual processing and perception, increasing the risk of falls.

The provider told us they were making arrangements for stair gates to be fitted to some stairways to reduce risks. Following the inspection the provider has provided evidence that these are now in place in some areas of the building.

The provider had installed digital key pad locks on some doors around the property to maintain the security of people who would be at risk of harm if they were not accompanied when leaving the building. We observed that some service users were pressing numbers on the key pads of doors, including external doors. The code to unlock these doors was a basic 4 digit code of sequential numbers, and the same code was used for all but one door at the service. Staff told us people did not know the code, however there was a risk that people could open a door accidentally by pressing the four sequential numbers.

Cleaning products and disinfectants were not all being stored safely in line with Control of Substances Hazardous to Health (COSHH) regulations and some people had cream for dry skin conditions that were left out in their rooms. This meant people with dementia had access to these products and were at potential risk of harm from ingesting them. We asked the provider to ensure these products were moved to safe storage.

Fire drills were not being conducted at appropriate intervals as stated within the provider’s fire risk assessment. Government guidance for fire safety in care homes recommends fire drills should be conducted at least annually. The last recorded fire drill was 26 February 2019. Some service users required emollient creams regularly. These creams had not been assessed for fire risks associated with flammable ingredients and Personal Emergency Evacuation Plans did not include use of emollient creams. This placed people at risk of harm in the event of a fire.

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

There were not sufficient suitable staff deployed to meet people’s needs at all times. Some people were observed to be alone on the first and second floors of the service with no staff to support them. Not all service users were able to use a call bell for support if they needed to do so. Three people with dementia were all showing signs of distress but there were no staff on their floor for approximately 25 minutes. At lunch time no staff were deployed to a lounge area where 4 people were waiting for their meal. A person became distressed, and this had a negative impact on the other people in the room. Staff who were nearby did not intervene to support people and there was no clarity about whether a staff member should have been deployed to this area.

Staff did not have all the skills, knowledge and guidance they needed to provide safe care. Training records showed that only one member of care staff had completed dementia training. Staff were not using clear strategies to support people when they became distressed, and care plans did not include guidance for staff in how to support people.

Staff were not receiving regular supervision meetings to provide support and professional development. One staff member said they did not know what supervision was and told us they asked other staff if they needed to know anything. Another staff member said they had not had any supervision. The provider told us staff were receiving supervision but there were no records to confirm this.

People and their relatives spoke positively about the staff. One person told us, “Staff are polite and support me.” A relative said, “My loved one gets their needs met and I have no problem with staff.”

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.

People and their relatives told us they were satisfied with the standards of cleanliness at the service. One relative said, “I have no concerns, it’s always clean and tidy.” We saw staff using appropriate Personal Protective Equipment throughout the inspection. Housekeeping staff were observed cleaning throughout the day. Audits were conducted consistently to ensure standards of infection prevention and control were maintained.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Systems for recording administration of medicines were not robust. We noted that a Medicine Administration Record (MAR) chart had not been signed for a prescribed medicine on one date. There was no record of the reason for this omission and there was no system for monitoring what the stock level should be for medicines. This meant the provider could not be sure whether the person had received their medicine as prescribed.

Some people were prescribed PRN (as required) medicines. There were no PRN protocols in place to provide guidance for staff about when these medicines should be given, whether people were able to request the medicine themselves, or what signs and symptoms staff should look for before offering the medicine. This meant people prescribed PRN medicines were at risk of not receiving this medicine safely or as prescribed.

The service had a stock of homely remedies. There was no system in place to ensure such medicines were administered safely and in line with NICE guidelines. Staff did not have information about how and when homely remedies should be offered, whether people were able to request these medicines themselves or when staff should offer the medicine. There was no information about which people should not be given certain medicines. For example, some people were prescribed paracetamol. Paracetamol should not be given as a homely remedy if a person is already receiving prescribed paracetamol. There was no information about any contraindications, for example if a prescribed medicine was not compatible with a particular homely remedy. This meant people were at risk of harm from not receiving medicines safely. A staff member who was responsible for administering medicines said these factors had not been considered.

Only staff who were trained and had been assessed as competent were able to administer medicines to people.