Bricklehampton Hall

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 not protected from avoidable harm.

The provider was in breach of the legal regulations relating to safe care and treatment, safe environments and safeguarding.

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 have an open, proactive and positive culture towards safety. They did not listen to concerns about safety. Where safeguarding concerns had been raised by a person in the service the provider had failed to identify or address the concerns. Lessons were not learnt to continually identify and embed good practice.

The provider had not been effective in identifying the areas of improvement in the home environment to reduce the risk of people injuring themselves.

Accidents and incidents were documented however information was not clear or accurate with monitoring forms showing differing accounts of incidents to what was recorded in peoples care records. The clarity in the records needed to effectively detail, review and monitor the frequency of falls and incidents in the service was not there. This meant opportunities to learn lessons from incidents and take action were missed.

Whilst the provider carried out an annual satisfaction survey with relatives and people in the service, this had not been effective in identifying some people's concerns about the care and support they received.

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. They did not always make sure there was continuity of care, including when people moved between different services.

While concerns were not always identified in a timely manner, relatives told us the provider worked well with health services when people needed it.

Some people told us they could see a doctor if they asked. We saw evidence of where people had the input of health professionals, however staff did not always follow the guidance and instruction in the care plans. For example, 1 person was assessed as requiring thickened fluids to help them drink and swallow safely. However, we found a cup in a person’s room containing fluid that had been over thickened to a paste consistency with a label written by staff stating it was ‘lumpy’ and left in reach of the person. This demonstrated that staff had noticed the drink was not thickened appropriately and failed to replace it with an appropriate drink, this left the person at an increased risk of choking and at risk of avoidable harm.

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, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Whilst the provider took action to safeguard some people when safeguarding incidents occurred, there were times when action was not taken in a timely way. The registered manager was made aware of concerns that had been raised to a family member by a person in the service. The registered manager did not take the necessary action to investigate it in a timely manner and did not follow the provider’s safeguarding policies and procedures. This resulted in further concerns being raised by the person before action had been taken. We raised several safeguarding concerns with the local authority following this assessment.
 

Staff had training in safeguarding and told us they understood their responsibilities to keep people safe, however some people told us they didn’t always feel safe.

The provider did not work well with people to understand and manage risks. Staff did not always provide the care and support in a way that was safe or supportive and enabled people to do the things that mattered to them.

Although care plans and risk assessments were in place regarding people’s mobility needs and detailing what aids or assistance people needed to move safely, staff did not always follow them leaving people at risk of injury. One person told us staff could be abrupt in the way they provided support, and another person described bruising from when staff moved them. By not measuring or engaging with people about the care and support they received risks were not discussed and strategies to better manage risks were not explored with people.

Environmental risks were not always identified or removed. We found areas of the home where work was still required to address potential trip hazards. This had not been discussed with people who had impaired mobility, and we were not assured steps to manage risks had been reviewed with people in the home.

People at risk of choking were not always safely supported as staff were not using the correct amount of fluid thickener per ratio of fluids. Staff were not always considering if the fluid had been thickened to the prescribed consistency. One person who was assessed as requiring thickened fluid, had their drink thickened to a paste like consistency, staff had labelled it as lumpy, leaving it in reach and ready to be taken by the person. This increased the risk of a person aspirating.

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 did not ensure the home environment was safe or well maintained. Adequate measures to reduce the risk of people falling from height out of windows had not been taken. It is a legal requirement to have suitable window restrictors, these were not in place when we visited. Sash windows which were open were propped open by objects, we saw air fresheners and blocks of wood being used to do this. Removal of these objects caused the window to shut suddenly. There were no assessments of these risks and this left people at risk of injury. Immediately following the inspection the provider has taken steps to address these issues.

Areas of the home contained black mould on walls. This had a potential impact of this on people’s respiratory systems. Although after the inspection the provider has told us this was treated, we were not given any evidence during the inspection that this was the case. Flooring was damaged and uneven in main communal areas increasing the risk of injury to people. Heavy furniture in people’s bedrooms were not all fixed to the walls, this posed a risk of furniture toppling onto people. Some furniture was broken and not safe, we found a chair in a communal area that had sharp pins protruding from it, posing a risk of injury. Doors to people’s bedrooms were not in line with current fire regulations, we contacted the fire authority who carried out an inspection and confirmed this, as well as identifying the fire alarm and smoke alarm systems needed replacing to ensure they were in line with current fire regulations.

The registered manager told us they did a daily walk around to check on the home and the service. These walk arounds were not always documented and failed to identify independently what we had found during our assessment.

Following the inspection the provider has taken steps to start to address the issues raised.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always 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.

We were not assured there were sufficient staff during the night. We were shown a dependency tool that the provider used to determine safe staffing numbers, however we found it did not account for people’s individual support needs and only reflected a ratio of staff to the numbers of people in the service. This meant people were exposed to risk their needs would not be sufficiently met due to a lack of staffing available. This placed people at risk of potential unnecessary harm.

Whilst our observations of care through the day did not highlight a shortage of staff and staff did not raise concerns over staffing numbers, people provided mixed views on how their needs were met. One person told us staff usually responded quickly when a call bell was sounded, however some people told us they often had to wait for staff to attend to them and sometimes this came too late to meet their personal care needs. One person when asking for assistance with toileting said they were told by staff to soil their clothes and they would be changed later.

The provider did not have a system to identify the times between a call bell sounding and the care need being met. The registered manager was unable to show us how they measured the efficiency of staff in responding to people’s needs, the lack of oversight to ensure staff dealt with people’s needs in a responsive and timely way were not identified, and opportunities to improve care and people’s experiences were missed.

Recruitment procedures for staff was robust and relevant background checks were carried out before staff started work. New staff had opportunities for training and shadowing as part of their induction into their roles.

The provider did not have an open, proactive and positive culture towards safety. They did not listen to concerns about safety. Where safeguarding concerns had been raised by a person in the service the provider had failed to identify or address the concerns. Lessons were not learnt to continually identify and embed good practice.

The provider had not been effective in identifying the areas of improvement in the home environment to reduce the risk of people injuring themselves.

Accidents and incidents were documented however information was not clear or accurate with monitoring forms showing differing accounts of incidents to what was recorded in peoples care records. The clarity in the records needed to effectively detail, review and monitor the frequency of falls and incidents in the service was not there. This meant opportunities to learn lessons from incidents and take action were missed.

Whilst the provider carried out an annual satisfaction survey with relatives and people in the service, this had not been effective in identifying some people's concerns about the care and support they received.

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.

The provider stored medicines safely and in line with current regulations. Care plans reflected people’s medicine needs and where people needed as and when medicines (PRN) appropriate protocols and care plans were in place. However, systems to ensure safe administration of medicines in line with prescribed instructions was not always effective. For example, we found an instance where staff had not identified a prescribing error and had continued to administer the incorrect dose of a medicine to a person. This placed the person at risk of side effects of the medicines and health needs being untreated. Where people had time sensitive medicines (for example people who are living with Parkinson’s disease) these were not administered within the prescribed times and left the person at risk of their condition not being treated effectively.

There were regular planned audits of medicines and also unplanned spot checks. These checks had not identified that people who required time sensitive medicines were not always getting their medicines within the prescribed time.

All staff who administered medicines had training and updates on medication.