Brookside

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 inspection we rated this key question good. At this inspection 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 the legal regulation in relation to safe care and treatment. The provider had not always ensured safe medicines administration, staff training, management of people’s health risks and environmental safety.
 

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety. Incidents and safeguarding concerns were not always identified or reported, and governance systems did not detect patterns or risks until inspectors highlighted them. As a result, the service could not be assured that learning was being shared with staff for opportunity for learning and improved practice. This increased the risk of action not being taken to promote people’s safety.

The provider did not always work well with people to establish and maintain safe systems of care. Although people were supported to attend external health appointments, risks relating to the environment, emergency evacuation, staff training needs and hydration were not adequately assessed or monitored.

People were not always protected from potential abuse. We found incidents recorded in care records that had not been escalated to the local authority until inspectors identified them. This increased the risk that people were not safeguarded appropriately. However, information was displayed within the service relating to reporting and escalating safeguarding concerns externally and staff had received safeguarding training. A relative told us, “It’s safe. I’ve asked [relative] if [relative] is happy and they said yes.” Where people needed to be deprived of their liberty, appropriate authorisation had been sought.

People’s risks were identified in care plans, but systems did not always ensure these were effectively managed in practice, particularly in relation to hydration, evacuation arrangements, and staff training for medical conditions people lived and needed support with. However, care plans did contain good information about supporting people with their emotional wellbeing. Staff we spoke with knew people well and how to promote their safety.

The provider did not always detect and control potential risks in the care environment. We identified environmental concerns such as broken furniture and window restrictors had not been fitted in line with national guidance. The provider could not evidence all actions related to their legionella risk assessment and electrical safety report were in progress or completed.

However, regular safety checks and servicing took place in areas such as mobility equipment, fire alarming systems and gas safety.
 

While we observed there were enough staff to meet people’s needs, staff we spoke with felt due to people’s changing needs staffing levels should be reviewed. A staff member said, “Staffing levels are about the same, but their needs are more.” Staff were recruited safely and received regular supervision. However, the provider could not demonstrate that staff were consistently trained and competent in key risk areas. We identified gaps in training and competency assessment for catheter care, oxygen therapy, dysphagia and emergency evacuation, despite people being supported with these needs.

Some aspects Infection control practices needed improvement. We found accessible used razors, damaged furniture that would not prevent ingress effectively increasing the risk of germs harbouring, and a communal bathroom was unclean and inconsistent fridge and freezer temperature checks that could increase the risk of infection. Externally we observed there to be items such as rubbish bags or furniture that needed to be disposed of. We found other communal areas and people’s bedrooms clean and free from malodour. A relative said, “The place looks spotless and clean, the staff are very helpful. Its a nice place and well looked after.’’

The provider did not always ensure people’s medicines were managed safely. We identified expired and undated topical medicines, which increased the risk of people receiving unsafe or ineffective treatment. We signposted the provider to this on the first day of our inspection but continued to observe concerns on our final visit. However, medicines were stored in the medicines room were manged safely. People had person centred care plans detailing how they preferred to be supported to receive their medicines.