Brandon Trust - 261 Passage Road 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 we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (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.

Accidents and incidents were monitored, reviewed, and any trends were explored. This included what the concerns were, what action had been taken to minimise further risks and any learning.

These were reviewed by the registered manager and by the provider to ensure risks had been minimised. The staff recorded this electronically so this could be monitored promptly and remotely to ensure appropriate actions had been completed swiftly. This also enabled them to share learning across the organisation where relevant.

A member of staff told us, “All staff now complete mandatory dysphagia awareness training to ensure staff understand the risks relating to choking and swallowing difficulties”. This had been in response to learning across the whole organisation.

The registered manager held regular meetings, where staff could share safety concerns and good practice. Daily handovers between shifts kept staff updated about any changes or concerns they needed to be aware of.

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.

The registered manager told us they were actively promoting the home to try and find suitable people to move to 261 Passage Road. This was because the home had 2 vacancies. They told us they had recently assessed a person, but they were not suitable due to the layout of the home. It was evident the manager would assess each person to ensure they were suitable and the home could meet their needs. This included working with other professionals, the person and their representatives. This would include the person visiting the service to meet with the other people living in the home to ensure they were compatible.

People had healthcare passports to support them when they were admitted to hospital or moved from one service to another to ensure continuity of care. This contained important information enabling health professionals to get to know people. This enabled them to make adjustments as needed, such as how a person communicated and the support they needed to make decisions.

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 were supported by staff who had completed safeguarding training and understood how to recognise and report any safeguarding concerns.Staff understood their role in reporting and escalating any concerns. They were confident the management team would take prompt and appropriate action to ensure people were protected.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the home. We found appropriate assessments and applications had been made.

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.

People’s risks were clearly identified, understood by staff and managed safely. People had detailed risk assessments and care plans to guide staff practice, including risks relating to choking, mobility, accessing the community, and risks associated with any health conditions.

Staff delivered care that was safe and supportive while enabling people to take positive risks and engage in activities that were important to them.

Where needed, people had a positive behaviour support plan that described triggers, early warning signs and strategies that people found helpful in reducing their anxiety. This included spending time in a quieter area of the home and opportunities to discuss their concerns or to spend time doing something they enjoyed. Staff described how a person was more settled and relaxed in their home due to the positive interactions from staff. It was evident staff knew people well and used positive interactions to support and involve people in all aspects of their daily lives.

Staff had guidance to follow in the event of a fall. This included clear workflow plans outlining actions to take, who to contact, and what staff should monitor over a 48-hour period. Staff used body maps effectively to support monitoring and ensure the ongoing wellbeing of individuals.Staff spoke positively about the support they received when a person experienced a fall, highlighting the input from external professionals and the advice provided. As a result of this support and guidance, the person had not experienced any further falls.

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 design and layout of the premises were safe and met people’s individual needs. The registered manager told us they were liaising with a person’s advocate in respect of a potential move to a ground floor vacant bedroom to ensure it was in their best interest. This was because the stairs were posing a risk to them. The registered manager said this was also taken into consideration for any new person moving to the service to ensure they could safely use the stairs.

The service had a routine maintenance programme. Staff told us, the lounge had recently been redecorated, and people had been supported to buy new cushions and accessories to make the lounge more homely. The registered manager told us they were planning to extend the garden patio, which would make it more accessible to people.

Staff were able to report any maintenance requirements. The registered manager responded promptly to a maintenance issue in the ground floor toilet where there was some exposed wood behind the toilet cistern which would make cleaning difficult. This had been replaced by day 2 of the assessment in response to our feedback. A relative told us, “The home is beautifully looked after, clean and safe”. Another relative said, “It doesn’t feel like a care home, it really feels homely”.

The home had systems to ensure the home was safe. This included checks on equipment, legionella checks, fire and gas appliances. Adaptations such as window restrictors and radiators being covered all helped to keep people safe. The staff knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment which people needed. This included moving and handling training.

Each person had a personal emergency evacuation plan. These considered the person’s mobility, health needs and behaviours that might affect how they left the building in an emergency. Staff and people had completed fire drills to ensure people could evacuate the home safely, whilst evaluating the effectiveness of safety equipment and evacuation plans.

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.

Staffing was planned to ensure there were sufficient staff to support people doing the things they wanted to do and keep them safe. Staff confirmed there was sufficient staff. A relative told us, “There is always sufficient staff working to support (name of person) and enable her to do the things she likes to do”.

People were protected by safe recruitment checks. These checks included obtaining a full work history, references and a Disclosure and Barring Service (DBS) check before staff started working at the service. DBS provide information about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff had the knowledge and skills required to meet people’s needs. New staff completed an induction and a probationary period to ensure they were suitable to work in 261 Passage Road. This included shadowing more experience staff.

All staff completed regular training building on their knowledge and skills to support people safely and in a person-centred way. Staff had received training relevant to people’s individual needs, including dementia awareness and managing distressing behaviour and specific mandatory training, which aims to improve the care and support provided to autistic people and people with a learning disability.This was closely monitored by the team leader, the registered manager and the organisation’s training department.

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 free from odour. Cleaning schedules were in place with deep cleaning taking place regularly. People were supported to help with household chores such as laundry and cleaning their bedrooms where they were able.

Staff had completed infection prevention and control training. Infection prevention and control policies were in place alongside regular audits to ensure policies were being followed.

A recent Environmental Health inspection had awarded the service a rating of 5. This is the maximum score. This showed food safety management systems, hygiene training, cleaning schedules, safety checks and records were compliant with regulations. Staff had completed training in food hygiene.

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

The registered manager followed national guidance, including STOMP to ensure people were not administered medicines unnecessarily. STOMP (Stopping Over Medication of People with a learning disability, autism, or both) is an NHS England program aimed at reducing the inappropriate use of psychotropic medicines. It focuses on reducing over-prescribing of antipsychotics, antidepressants, and sedatives used to manage behaviour, rather than treating underlying mental illness. A new audit tool had been devised to ensure people’s medicines was appropriate and in line with the national guidance.

The staff had been proactive in reducing a person’s epilepsy medication working closely with health professionals. This had a positive impact on the person who was more engaged and relaxed. A relative told us, “The staff have worked tirelessly to investigate (name of person’s) medical needs and make sure these were investigated. This has resulted in her medication being altered. We are so grateful”. In addition, staff told us a sedative that had been prescribed was no longer needed. This was confirmed in records we viewed. This demonstrated a person-centred approach and collaborative working with health professionals ensuring the person was at the centre of all decisions. Another person liked to stay in bed until late morning, staff had proactively liaised with the GP to agree that the morning medication could be given later. This enabled the person to remain in bed without disruption in line with their preferences.

People's individual medicines were stored in a secure cabinet in their rooms. This helped staff to provide a more person-centred approach to the administration of people’s medicines. Each person had a medicine profile describing how they wanted to be supported and information about their medicines and any side effects. Medication administration records were maintained of all medicines administered.

Staff received training in medicines management, and their competency was checked before they were authorised to administer medicines. The service had a medicines policy which clearly described the process in place to report and investigate medicine errors and incidents. The management team carried out regular audits of medication practices to ensure they remained safe and effective.