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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had systems for logging and investigating falls, incidents, accidents and safeguarding concerns. Clinical staff carried out a ‘root cause analysis’ following each fall to identify areas for improvement and people were consistently monitored after a fall to check on their wellbeing.

The provider responded to concerns and used feedback to improve care. We saw significant improvements since our last inspection.

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.

People’s care and support plans were regularly reviewed to ensure they remained reflective of people’s needs. This meant staff were able to provide up to date information to healthcare partners when people’s needs changed.

The service worked with a range of external professionals including GPs, frailty team and other healthcare services to support people's ongoing needs.A healthcare professional told us, “The staff are very attentive to my requests for assistance with the residents and also generally very good at following care plans which we decide on.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us they felt safe at Bricklehampton Hall. One person’s relative told us, “We couldn’t be happier that they’re here. The staff are marvellous. There are people here to look after them and be respectful.”

People were protected from the risk of abuse. Policies relating to safeguarding and whistleblowing were in place. Staff had received training to enhance their understanding of how to protect people from any form of discrimination and were aware of when and how to report concerns. Staff felt confident concerns raised would be dealt with appropriately. A member of staff told us, “I would report suspected abuse to the manager, if needed to the director or regional manager.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were identified and mitigated effectively. People’s care plan’s included clear guidance for staff on how to protect people from identified risks such as risk of choking, risk of falls or risks related to an epileptic seizure. People had the equipment they needed to help keep them safe, such as walking frames and sensor mats to support their mobility. Management regularly reviewed care plans and risk assessments

Personal Emergency Evacuation Plans (PEEPs) had been developed to inform first responders and staff of the support people would need in the event of an emergency.

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 environmental issues identified during our previous inspection were in process of being addressed by the provider. We saw improvements including new plastering and we saw the affected mould had been treated. The registered provider restricted access to the areas outside due to uneven pavement and was in process of contacting other organisations to resolve this issue.

Fire and water checks were carried out regularly, and detailed records were maintained for all servicing and checks. The registered manager carried out regular audits of the home and the environment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Some staff had worked at the service for many years, which helped provide consistent care for people. During the inspection we observed call bells were answered in a timely manner.Staff were visible, were not rushing, and took time to sit and talk with people. A member of staff told us, “At the moment we have enough staff.”

Staff received support through observations, supervisions and appraisals with their team leaders. This gave them the opportunity to discuss their role, concerns and training needs as well as personal welfare. Staff told us they felt well supported by their leaders. A member of staff said, “I find supervision useful. I can raise my opinion, my concerns. We also have staff meetings every month.”

New staff were recruited safely, following appropriate recruitment procedures, including Disclosure and Barring Service (DBS) checks and verification of relevant employment history. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Recruitment records were up to date, and all staff were up to date with their training.

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 tidy. There was an up-to-date policy on the control of infection, prevention and control (IPC) which staff could refer to if needed. Staff had access to personal protective equipment (PPE) to use when carrying out personal care tasks.

Relatives and professionals told us they felt the home was clean and they recognised recent improvements within the service. A relative told us, “The floors are always hoovered.” A healthcare professional commented, “I have noticed that they appear to be having improvements made within the building e.g. decor, carpets.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff received training and regular competency assessments to support safe practice. Audits and routine checks were completed to provide oversight of medicines management and identify any areas requiring action.

Medicines were stored safely. Medication rooms were temperature controlled and records of temperature checks showed rooms and medicine fridges were maintained at suitable temperatures. Records showed people had their medicines administered on time, as prescribed.

We reviewed medicines administration records (MAR) and found these had been completed correctly, with no unexplained gaps. Clear processes were in place for the safe storage and disposal of medicines.

Some people were prescribed medicines on an ‘as required’ basis. Personalised protocols gave staff guidance about how each person would express the need for these medicines and included specific strategies staff could deploy to support the person prior to administering medicines.