Brooklyn House 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 good. At this assessment the rating has changed 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. The service was in breach of legal regulation in relation to people’s safe care and treatment.

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 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 structured daily meetings enabling staff to communicate concerns to the registered manager promptly. Registered nurses attended a monthly clinical meeting where people’s wellbeing and health needs were discussed for continuity of care. Lessons learnt from incidents were discussed at monthly team meetings to enhance learning and development.

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.

Before people joined the service the registered manager completed a thorough preassessment to ensure that the service can support people’s needs and to enable a safe transition from their home or another service.

We found people were supported in accessing appropriate healthcare professionals for their health needs. For example, people were receiving support from GPs, speech and language therapy (SALT), and dietitians.

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 protecting people’s right to live in safety.People were at risk of being unlawfully deprived of their liberty due to Deprivation of Liberty Safeguards (DoLS) applications not always being submitted promptly when needed, for example we identified a person who had not had a Mental Capacity Assessment (MCA) completed and the person’s care plan stated they had Alzheimer’s disease and experienced short-term memory loss. When we informed the registered manager, an MCA was completed and subsequently a referral to DoLS was made for this person.  Staff received safeguarding training and demonstrated a clear understanding of the services procedures of reporting concerns. 

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. Risk assessments were in place for people needing to be repositioned regularly due to risk of skin damage. However, we found some people were not being repositioned in line with their risk assessment. For example, we found monitoring charts for some people who required support to reposition every 4 hours to reduce the risk of skin damage, were being repositioned for longer periods than 4 hours. When we informed the registered manager, they were proactive in reviewing our concern. The registered manager reviewed all people at risk and ensured regular oversight was made.

The provider did not always detect and control potential risks in the care environment. During our inspection we found people’s toiletries were not always stored safely, portable oxygen cylinders were stored in an unventilated cupboard near people’s rooms, heaters had plastic covered metal cages over them, we found 2 heaters in corridors with these cages, which did not prevent access to the heaters hot surface. This put people at risk of harm.

When we raised the concerns with the provider, they acted promptly to manage changes and put strategies in place to protect people from the risks we identified. However, we are not assured the providers systems and processes would have identified these areas of improvement themselves.

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.

The provider had an effective rota system to ensure staffing levels reflected the needs of the people the service supported.

Staff told us there were appropriate numbers of staff on duty to meet people’s needs. Relatives told us they felt there were enough staff on duty when they visited the home. A relative told us,

“I do think that there are enough staff. They are very good.”

The provider did not always assess or manage the risk of infection. For example, we reviewed the cleaning records. The records covered daily, weekly, bi-weekly, monthly and quarterly tasks for the housekeeping team of the service. We found substantial gaps in daily records for all areas of the home. The provider’s infection control audit processes did not identify the gaps in cleaning records. The home presented clean. However, we were unable to confirm if areas were cleaned as directed.

The staff had received infection control training, and we observed staff wearing personal protective equipment (PPE) when supporting people with their care needs.

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.

People’s medicine’s records showed that they received their medicines safely and as prescribed. Staff were knowledgeable about people and their medicines.

There were suitable arrangements for ordering, storage and disposal, including medicines requiring cold storage and those requiring extra security. Suitable temperature monitoring was carried out to make sure medicines were safe and effective.

Staff had suitable, up to date training, and the provider carried out medicines audits to support safe medicines management.