Bromson Hill 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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurances about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to the environment, safeguarding and people’s safe care and treatment.
 

This service scored 41 (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 always have a proactive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider did not have effective systems to ensure accidents and incidents were consistently reviewed, analysed and used to drive improvement. Learning from incidents was not always effective in identifying underlying causes and informing actions to mitigate risks and prevent reoccurrence. People’s care records were not always updated when risks were identified to guide staff on how to support people safely, including when people had fallen, behaved in a way that posed a risk to themselves and others, or were at risk of malnutrition.

This meant the provider could not demonstrate effective action had been taken to reduce identified risks, limiting the ability to learn from incidents. The registered manager told us lessons learned from incidents were discussed with staff during meetings. However, records did not support this. We reviewed documentation from the most recent staff meeting, held in December 2025, and found no evidence learning from recent accidents, incidents, or concerns had been shared with staff. This limited the provider's ability to promote reflective practice and ensure staff learned from events occurring within the service.
 

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.

When people moved between services, systems were in place to share information about their health needs, medicines and preferences for future care. However, inaccuracies and contradictory information in people’s care plans meant we could not be confident the information shared was always accurate or sufficient to support safe transitions.

One person was going to a hospital appointment on the day of our inspection. The registered manager had increased staffing levels, so a member of staff was available to accompany the person to their appointment.

Staff contacted external healthcare professionals promptly when they needed advice or people required additional assessment or support. However, the lack of consistently accurate records meant there remained a risk essential information could be missed or not communicated effectively.

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.

Safeguarding systems and processes were ineffective in ensuring concerns were identified, reported, investigated, and escalated appropriately. Records did not consistently demonstrate safeguarding incidents had been recognised or managed in line with local safeguarding procedures.

We found several examples where potential safeguarding concerns had not been identified or acted upon. One person had recently absconded from the service, however, the registered manager had not reported this incident to the local authority or notified us, CQC, as required. Another person had experienced a fall where equipment was either ineffective or had not been used in accordance with their care plan. Despite the potential risk posed to the person, this had not been considered or recorded as a safeguarding concern.The same person had been found to have bruising in another area. Records stated the suspected cause was ‘improper manual handling’ but again this had not been highlighted for safeguarding consideration.

A further person had fallen, but records lacked sufficient detail to enable the registered manager to determine whether the incident met the threshold for safeguarding referral. This demonstrated weaknesses in incident reporting and management oversight, increasing the risk safeguarding concerns could go unrecognised.

Staff knowledge and understanding of safeguarding was not always sufficient to protect people from harm. Records showed staff had observed behaviours that placed people at risk of harm to themselves and others, however, staff had not been escalated these concerns for management review or consideration as potential safeguarding issues. Opportunities to identify and respond to safeguarding concerns were repeatedly missed.

The provider had failed to establish effective systems to monitor safeguarding concerns, identify patterns or trends, and ensure appropriate action was taken. Oversight was poor, and there was a lack of professional curiosity when incidents occurred. As a result, people were exposed to the risk of harm and could not be assured they were receiving safe care in an environment where safeguarding responsibilities were understood and consistently applied.

Following our feedback, the provider submitted safeguarding referrals to the local authority for consideration, and notified us as required.
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans did not consistently identify risks to people or provide clear guidance for staff on how to support people to manage those risks safely. People’s care records lacked accuracy which meant staff did not always have the information required to deliver safe and effective care.

For example, 1 person's care plan stated they required a hoist for all transfers and regular repositioning in bed using a slide sheet. However, the registered manager confirmed this information was incorrect, and the person was able to transfer using a walking frame and independently reposition themselves in bed. The same person's care records stated they had bedrails in place and were likely to ‘put their legs over the rails and try to jump.’ Despite this known risk, there was no bedrail risk assessment in place to determine whether the use of bedrails remained safe, appropriate and in the person's best interests.

Another person's records identified they were living with diabetes, however, there was no diabetes care plan in place. As a result, staff did not have guidance on managing the condition, recognising signs of fluctuating blood sugar levels, or responding appropriately should concerns arise.

People were also exposed to environmental risks due to poor safety practices. Thickening powders, used to reduce the risk of choking for people with swallowing difficulties, were not stored safely. We observed thickening agents left on bedside cabinets and overbed tables in people's bedrooms. The provider had failed to ensure appropriate controls were in place to mitigate the known risks associated with accidental ingestion of these products.

Systems to manage the risk of pressure damage were also ineffective. Some people used pressure-relieving mattresses to reduce the risk of skin damage; however, systems were not in place to ensure the mattresses were set correctly to their weight. On day 1 of our assessment, we found mattresses set inaccurately, meaning people may not have been receiving the level of pressure relief required to protect their skin. Despite sharing our findings with the registered manager when we returned on day 2 of our assessment, we found this potential risk remained.

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 had not ensured the environment was consistently safe or well maintained. During our assessment we identified multiple environmental hazards that placed people at risk and demonstrated a lack of effective oversight. Several areas of the home were in poor condition, including worn and damaged woodwork and rotten window frames, indicating maintenance issues had not been addressed in a timely manner.

Renovation work was being undertaken in a bathroom on the first floor. The bathroom had been left unsecured, allowing people access to contractors' equipment and materials. We observed exposed insulation rolls and holes in the floor where floorboards had been removed. These presented risks of injury, including trips, falls, skin irritation, eye damage and respiratory irritation from exposed fibres.

Window safety was not adequately managed. We saw several broken and inadequate window restrictors in the home. Other windows did not have the correct window restrictors as described in Health and Safety guidance for care homes. Window restrictors reduce the risk of people falling from height. We found some wooden windows and windowsills were in a poor condition so we could not be confident the windows themselves would withstand the forces required, with or without restrictors.

Further hazards were present within people's living areas. One person's bedroom contained a wire running across the floor which remained a trip hazard despite attempts to secure it with tape, as the tape was split and worn. We also observed a deep and wide track for a sliding door between the dining room and conservatory, creating a potential trip hazard, particularly for people using walking aids.

These concerns demonstrated environmental risks had not been effectively assessed, monitored or mitigated. The provider had failed to maintain a safe environment and had not taken sufficient action to protect people from avoidable harm.

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.

Staffing arrangements did not always ensure people received care from suitably recruited, trained and competent staff. Safe recruitment processes had not been consistently followed.

One member of staff was working in the home without the required pre-employment checks having been completed. This included the provider not obtaining evidence of the staff members identity and not completing a Disclosure and Barring Service (DBS) check, in line with regulatory requirements. The member of staff was working unsupervised and had keys and access to all areas of the home. This placed people at potential risk as the provider could not demonstrate the individual was suitable to work with vulnerable people. Following our feedback, the provider took action to complete the necessary checks.

Systems to support staff induction and development were not robust. Induction records were either unavailable or inaccurate, meaning the provider could not demonstrate new staff had completed a structured induction or been assessed as competent before undertaking their roles. While mandatory training had been provided, most training was delivered online and there were no effective systems in place to assess staff understanding, competence or the application of learning in practice. As a result, we could not be assured staff had the knowledge and skills necessary to consistently provide safe and effective care. Not all staff received regular supervision.

There were sufficient staff to provide the care and support people required. Staff told us there were enough staff deployed to keep people safe, respond to their needs promptly and provide care without feeling rushed. During the assessment, we observed staff were visible, responsive and available to support people when required.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control systems were not consistently effective in ensuring people were protected from the risk of infection.

There was a lack of effective maintenance of the premises to ensure infection control risks were minimised. For example, areas of woodwork were scuffed and chipped which made them difficult to clean. Clinical waste bins were damaged and had not been maintained to an appropriate standard. Some furniture and carpets were worn and stained, and many windows needed cleaning, inside and out.

The cleanliness of the environment required improvement. We observed some areas of the home were dusty and contained cobwebs, indicating cleaning practices were not consistently effective. Cleaning records showed deep cleaning had not been completed in line with the provider's own expectations, with some rooms not having received a deep clean for several months.

Although staff had completed Infection prevention and control (IPC) training, we were not assured this learning had been fully understood or embedded into practice. For example, staff told us they used handwashing sinks to clean some continence equipment. This practice presented a risk of cross-contamination and did not reflect best practice in infection prevention and control.

IPC audits had not been completed in line with the provider's expectations, and the audit tool in use was not sufficiently robust to identify the concerns we observed during the assessment.

Personal Protective Equipment (PPE) was seen to be readily available to staff. The registered manager ensured staff understood the importance of good hand washing through routine checks and displayed information.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We could not be confident that people always received their medicines safely or as prescribed.

The provider had not ensured robust systems were in place to support the safe administration, recording and oversight of medicines.
Where people received their medicines covertly, there were not always clear directions in place to guide staff and document how medicines should be administered. Staff responsible for administering these medicines told us that, in most cases, medicines were crushed together and given as a single dose. However, there was no documented evidence to demonstrate this practice was safe or in accordance with prescribing guidance and best practice. This increased the risk of medicines being administered in a way that could affect their effectiveness or safety.

Some medication administration records (MARs) were of poor quality and 1 was illegible. This meant staff did not always have access to accurate, complete and easily understandable information when administering medicines. This increased the potential for errors.

In addition, discrepancies and omissions within medication records had not been identified or addressed through routine checks and monitoring processes. These recording issues increased the risk medicines may not be administered as prescribed and demonstrated insufficient oversight of medicines management practices.

Records for topical cream applications also required improvement. Whilst staff recorded creams had been applied, records did not always specify which cream had been used or the area of the body to which it had been applied. This meant there was not always a clear audit trail to demonstrate creams had been applied correctly.

Despite these concerns, there were examples of good practice. Controlled drugs were managed safely, with daily audits completed by nurses, and appropriate records maintained. Medicines were ordered in a timely manner and stored securely. Staff worked closely with a clinical pharmacist who visited weekly to review people's medicines. A healthcare professional told us staff were proactive in reviewing medicines and supporting the reduction of medicines which were no longer required.