Brookfield Care 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 this key question was rated good. At this assessment the rating has changed from good to 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. Risks to people’s health and safety were not always safely assessed and there were shortfalls in relation to how medicines were managed. There were enough experienced and trained staff to support people. The home was well maintained, clean and homely. The provider was in breach of the legal regulation in relation to people’s safe care and treatment and the way people’s medicines were managed safely.

This service scored 56 (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. Staff 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.

Accidents, incidents and near miss events were not always reported and action was not always taken to mitigate the risk of events happening again. For example, staff were not consistently escalating incidents of distressed or complex behaviours, which impacted on other people. Some staff documented these behaviours as emotional needs within care notes, rather than as incidents, which meant the manager did not always maintain effective oversight. We discussed this with the manager and they took action to advise and support staff. People had access to professionals, family and friends outside of the service who they could raise concerns about their safety with.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Continuity of care for people was maintained, and records showed people were supported to access a range of health and social care appointments. Staff told us where people needed support with communication they attended appointments with them. Where needed, referrals were made for specialist advice. People were assessed before they moved into the home to ensure the service was able to meet their needs.

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.

The provider had processes in place to manage safeguarding events and there was a log in place. The provider worked collaboratively with the local authority to support people safely. However, staff did not always recognise safeguarding events and report these promptly. We identified a safeguarding event which had not been reported to the local authority. Staff had training in safeguarding and were able to tell us how to recognise and act upon concerns about poor care and abuse. Most people and relatives told us they felt safe living at the home.

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, supportive and enabled people to do the things that mattered to them.

Risks to people’s health, safety and wellbeing were not always recognised, assessed and acted upon. There were contradictions in people’s care records which meant staff did not always have clear guidance about the risks they were exposed to, including people’s mobility, hydration and nutritional needs. For example, there were contradictions in people’s care records about their dietary needs and about whether a person could walk or needed the use of a hoist to be able to mobilise. Where people presented with complex behaviours there was a lack of monitoring of potential triggers or guidance to staff about how best to support them. This meant their behaviours could be misunderstood and they may not receive consistent support. Records showed 1 person’s behaviour had changed over time. This had escalated and responsive action had not been taken to mitigate this. This meant they, and other people, were at risk of harm and poor care. The manager took action and told us they would introduce enhanced monitoring to better understand potential triggers and strategies for de-escalating behaviours. The manager had recently undertaken a review of the falls people had experienced and the action taken, in relation to this, had led to a reduction in people falling.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The home was well equipped, maintained and had high quality décor and furnishings. Building and safety checks were in place. People and relatives told us the home was safe and homely and we saw there were accessible features, including access to a safe outside space and a range of communal areas. However, the provider had purchased beds for most people which contained integral bedrails, which were not secured and most people were not assessed to need them. Health and safety guidance highlights robust and individualised risk assessments should be in place, where people have bedrails. There were no risk assessments in place.

There were enough qualified, skilled and experienced staff, who received effective support, supervision and development. People told us they had good relationships with the staff.

Recruitment was managed safely and there were good systems in place to induct and ‘buddy’ new staff. Staff confirmed they received training and support, and the provider had a dedicated training venue. However, we found training had not always been effective in ensuring staff understood care records and the importance of documentation being up to date. Some staff had recently received interactive training on the subject of dementia and they told us this had supported them in their role.

There was a dependency tool in place to assess how many staff were on duty and this was regularly reviewed. However, this did not consider the layout of the building. We concluded there were enough staff to support people safely. However, we saw staff were rushed at times and focused on tasks. This was confirmed by our observations and feedback with people, relatives and staff. Comments from staff included, “There is not as much time to chat with residents as we would like. When we have to prioritise care like turns, we don’t always much time to spend with residents during the day.”

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.

Staff received training in infection, prevention and control and understood the importance of high standards. We observed staff following safe practices when supporting people, including wearing aprons and gloves. There were regular checks on staff’s understanding and competency.

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

Medicines were not always managed safely. Where people were prescribed thickeners, there was contradictory guidance about the level their drinks should be thickened to. This exposed them to the risk of choking. Topical medicines, such as creams, were not always stored safely. We saw multiple examples where creams were stored openly in people’s en-suite bathrooms and there were no risk assessments in place to support this practice. Where people were prescribed medicines to be taken 4 times daily, medication administration records did not highlight the time it had been administered, which meant there was a risk there may not be a 4 hour gap between doses. One person was administered a variable dose of a medication and the number of tablets offered was not always recorded. We were assured the manager had taken robust action to address these shortfalls.

Other medication systems were organised and stock checks were accurate. Staff received training and there were processes in place to ensure their competency was regularly assessed. When administering medication, staff supported people patiently and kindly.