Bromford Lane Care Centre

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 inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 2 legal regulations in relation to safe care and treatment, due to inadequate care planning and risk assessment, and staffing.

This service scored 25 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not robustly investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the service still required improvements in relation to the focus on safety and learning. We continued to find that many known risks to people were not adequately assessed and further information for staff was needed about how the risks would be managed. The system in place for the analysis of incidents, including displays of distress which people expressed, was not robust or effective. This meant there were continued missed opportunities to drive improvements in the service from lessons learnt in relation to incidents which occurred. For example, where investigations or analysis had taken place of incidents of distressed behaviours these had not identified how people could effectively be supported by staff. This meant there was a lack of understanding of how to reduce the risk of reoccurrence. Although there was a record of complaints or compliments which were received, this did not include complaints people, or their relatives told us they had raised during the inspection. This meant the records did not reflect the number or type of complaints received in the service. There was no analysis of complaints to support future learning and improvements. There was also a lack of robust evidence to demonstrate outcomes of any learning was discussed with staff. A lack of clear and consistent guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were sometimes lost or delayed.

Some relatives told us at times they found it difficult to contact the service if they had any concerns about their loved one’s care, with some experiencing a lack of responsiveness from the manager. Most told us they knew who to speak with if they needed to.

The provider did not consistently work well with people and health system partners to establish and maintain safe systems of care. They did not make sure there was continuity of care, including when people moved between different services to promote safe transfers.

We continued to find the systems which were in place for assessing people’s needs prior to moving in, were not robust. Assessments, particularly for the EAB unit, continued to be carried out remotely with no face-to-face contact with people moving in or their representatives. This system, at times, resulted in placements not being suitable as the service was inadequately prepared to meet the complex needs of people. This, and the lack of reviews involving people or their representatives, had also resulted in avoidable hospital admissions. Records held by the provider failed to demonstrate there was consistently adequate information for robust continuity of care, including when people moved between different services. This included when people transferred to hospital due to their health conditions having deteriorated.

Most staff we spoke with knew people and their support needs well. However, we found that agency staff supporting people with complex needs did not have good insight of people’s needs, wishes, likes and dislikes. Agency staff were being used on a regular basis to support people in the service.

There continued to be shortfalls as the provider had failed to monitor and audit the records of the care and support provided by staff, ensuring records and subsequent actions were clearly documented. This included areas of support such as repositioning where a person had developed a pressure wound requiring the support of a district nurse; oral health care where records indicated some people had not been supported with oral care for many days during the month and there was a lack of evidence of support with showers and bathing.

Some relatives told us they felt informed and involved when their loved one was moving into the service and were kept up to date with changes verbally. However, some relatives told us of the related issues they had faced and had not felt involved or listened to.

The provider did not consistently 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 potential abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

We found the provider continued to fail to demonstrate a firm understanding of their safeguarding responsibilities and had not recognised or responded appropriately to potential abuse. We found multiple safeguarding incidents where the provider had failed to notify CQC of these events. When we spoke to the staff member responsible for completing such notifications, they lacked understanding of when they should alert CQC.

Whilst we saw that investigations into incidents took place, lessons learnt were not robust. The provider had not evidenced that lessons had been acted upon or shared with the wider staff team. This meant we could not be assured people were safe from ongoing safeguarding issues. At this assessment, we found a widespread failure to recognise potential abuse and protect people from potential harm and report such concerns. For example, for numerous people who had sustained unexplained bruising or injuries there was a lack of investigations to ascertain the root cause. We continued to find a lack of guidance on management of known risks and health conditions for those people whose support plans we reviewed. We raised safeguarding concerns due to the lack of systems to keep people safe.

Staff had received safeguarding training and told us if they had any concerns in relation to suspected or actual abuse, they would speak to the nurse or registered manager. Not all staff knew how to escalate concerns with other organisations. Overall people told us they felt safe with the staff supporting them although some relatives raised concerns around the standard of care and support people received.

Some relatives told us they were contacted by staff and management following incidents occurring or new risks emerging involving their loved ones. Most told us they received information about changes to people’s support needs, but this was not consistent for all. Some relatives of people who lacked capacity to make their own decisions told us they had been involved with applications for Deprivation of Liberty Safeguards (DoLS) authorisations and meetings about decisions made in people’s best interests. Others told us they felt their loved ones known risks were well managed. However, we saw that risk assessments did not always fully reflect people’s rights under the Mental Capacity Act 2005 (MCA) and best interest decision-making did not always take place to demonstrate decisions made on behalf of others were in their best interests. For example, for 1 person we found monitoring equipment had been used without any capacity assessment or best interest meeting taking place. This restriction had not been assessed in line with the person’s rights under the MCA. This monitoring was taking place 24 hours a day, 7 days a week and there had been no consideration to the person’s privacy or dignity.

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.

At this assessment we continued to find that risks to people had not always been assessed with them or clear plans developed. Some people's care plans lacked clear guidance for staff about their role in monitoring and providing a consistent approach. The system for involving people and relatives when assessing, managing and updating risks was still not inclusive. Initial care plans for people moving into the EAB unit continued to be written by a staff member working remotely. They were based on the information shared by the hospital on discharge. Subsequent care reviews also continued to be carried out remotely without face-to-face reviews taking place. This process did not include people or their loved ones. Decisions had been made by the management team to remove call bells and shower curtains based on risks. However, this was not with consideration of people’s individual assessed needs and no clear rationale for these decisions had been recorded.

Risk assessments lacked clear guidance for staff to follow about how the risk should be managed. This included a lack of clarity on how to manage risks relating to people’s specific health conditions. For most people who we reviewed, some known risks had not been assessed. There was a lack of guidance for staff about how these risks should be managed, which had the potential to put people at increased risk of harm. There was a lack information to support a person who may become distressed, which increased the risks to both the person and staff members. We saw staff members supporting people with complex needs had not had the opportunity to receive the relevant, in-depth training in people’s health conditions. Basic on-line training had been provided on health conditions, without any follow up by the provider to assess staff’s understanding and learning. This meant they could not be assured staff had the appropriate skills and knowledge to support people safely. In addition, 1 staff member we spoke with did not know the name of the person they supported, nor their needs and wishes.

Despite our findings there was no evidence that people had been harmed. Most staff knew people’s needs and told us they understood how to manage people’s care in a safe way. Overall people were supported by consistent staff although agency staff use had recently increased and the process to ensure agency staff knew people they supported needed to be improved.

The provider did not always detect and control potential risks in the care environment. They did not make sure that facilities and technology supported the delivery of safe care.

At this assessment we continued to observe multiple environmental hazards with a lack of risk assessments in place to ensure safety was always maintained.

We found environmental issues both internally and externally which had not been identified by the provider. We observed exposed electrical wires which were accessible to people using the service inside the building and outside we observed poorly maintained garden areas. The garden areas had nails protruding from gates and fences, barbed wire hanging down from the fence. There were 2 unused aviaries which had been decommissioned for nearly 12 months which still had food and faeces in them. Although we saw no evidence this had caused harm, there was a potential of harm to people due to disease and germs carried by both the pets and pests. Smoking areas had a build-up of cigarette ends and did not have suitable receptacles for people to safely put out their cigarettes. This could have resulted in a fire causing harm to all in the service. All these areas were accessible by vulnerable people with complex health needs. This meant people were placed at risk due to poor environmental safety.

We observed a cleaning trolley which contained harmful cleaning products left unattended in a corridor which could have been accessed by people living in the service. There was a storage room which was unlocked and contained large pieces of equipment which had the potential to cause harm or injury should a person access this area. Although the provider had installed lockable cabinets for the storage of thickening products for drinks, we found on 1 occasion that 4 tubs of thickener had been left unsecured and accessible to people. This had the potential to cause harm or even death should the thickener be ingested without being mixed with adequate fluids.

We continued to find that managers had failed to follow the robust processes to manage the safety of the care environments, exposing people to risks. There were audits and checks carried out in line with health and safety guidelines, to ensure equipment was safe for use. There were maintenance staff working in the home who had a system where staff recorded and reported areas or equipment requiring repair.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The provider continued to fail to ensure all staff received appropriate training to meet the needs of people and their known health conditions. This was of particular concern in relation to the management of diabetes and modified diets. Whilst most staff we spoke with told us they felt they had received enough training to support people with their known health conditions; we found a lack of escalation where people’s blood sugar levels were outside of the safe range. We found practices which had not been suitably risk assessed placed people at risk of harm or even death.

We observed some staff who did not respond appropriately or seek further support when a person exhibited distress. However, we also observed some good staff interactions to help de-escalate distress and keep people safe. Staff members told us they had received training and induction from the provider and had the opportunity to shadow other staff members prior to supporting people. However, we found not all staff had received adequate inductions or supervisions during their probationary period to assess their learning, skills and knowledge. Our observations of, and conversation with, staff reflected this lack of adequate staff induction and supervision. Assessments of the effectiveness of staff learning in key areas was not consistently completed. For example, competency checks of staff skills had not been completed to observe their practice in areas such as supporting people with complex dementia or distressed responses. The provider and registered manager had also failed to carry out spot checks to ensure staff supported people appropriately. This meant the provider could not be assured staff were safely and effectively applying their learning when supporting people.

Staff supervision had been completed and recorded; however, these meetings were not always used to help drive improvements in the service.

The provider's recruitment systems were not robust. Safe recruitment practices were not always followed. People were at risk of harm from receiving care and support from unsuitable staff. We found references obtained had not always been verified as completed by the intended referee. Some references were not from the staff member’s most recent employer and prospective staff’s personal identification had not always been checked. The provider had failed to evidence that they had explored gaps in employment records for some staff and mitigated any associated risks. The provider failed to ensure they had obtained all the information required to assess the suitability of all staff employed.

We observed numerous agency staff members working in the service. The provider had failed to ensure there was a robust system in place to verify the identity and suitability of these. This meant when agency staff arrived, they could not be assured it was the person who they had booked. They also failed to carry out and record inductions into the service to familiarise agency staff with the building, key procedures and people they were to support.

This meant people were placed at risk as the provider had not carried out consistent checks to ensure all permanent and agency staff on site were suitable.

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.

We observed housekeeping staff carrying out their cleaning duties; however, some chairs in communal areas had a buildup of debris under the cushions. Throughout the service we identified areas of exposed paintwork and wooden furniture, which was porous making it hard to clean effectively, and furniture with worn and cracked coverings which could harbour bacteria. In the laundry area there was a linen trolley for dirty linen with a porous wooden top. We also observed a buildup of dirt around toilet bases and on flooring in bathrooms; leaks in ceilings which had not been repaired; chipped crockery in use in the dining areas and kitchen cabinets with chipped doors and surfaces. All the above areas posed an increased risk of infection to people who used the service.

There was a policy and procedure in place for infection prevention and control (IPC). There was a daily walkabout carried out by the care coordinators which included checking staff members’ IPC practices. IPC audits were carried out 3-monthly to ensure standards of good practice were upheld; however, the provider’s IPC audits failed to identify the concerns we found in the service. After we brought these concerns to the attention of the provider, they took action to order new furniture, created a new dining area and replaced the broken or porous cabinets.

We observed good practices in relation to the safe and correct use and disposal of personal protective equipment (PPE).

People and relatives we spoke with did not raise any concerns in relation to standards of cleanliness or hygiene within the home.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

The provider failed to ensure people’s medicines were consistently managed safely and in line with current legal requirements.

People’s support plans were not always clear in relation to the level of support they needed with medicines. This meant there was a potential for people not being supported with their medicines, as required.

We found that information for staff members to follow for 'as required' (PRN) medicines, to ensure a consistent approach, was still not always clear as to how, when or why to use such medicines. Without clear protocols in place, this could result in staff not knowing when to give these medicines, leading to the potential for too much or too little PRN medication to be given. For example, for 1 person who was known to have distressed responses, we saw guidance failed to inform staff when to escalate this to the nurse in charge to assess whether it was appropriate to administer ‘as required’ medicines to help relieve the person’s distress. There was also a lack of guidance on steps to take prior to the use of PRN medicines for this person.

We found staff had not received adequate training in relation to the safe management of blood sugar levels for people living with diabetes. We observed from records that on occasions blood sugar levels had been dangerously high, yet nursing staff had not sought medical advice or reported this to the management team. Nursing staff had continued with the person’s normal insulin regime. They had not retested the blood sugar levels and did not have access to testing strips to see if the person was at risk of life-threatening diabetes complications caused by a severe lack of insulin.We brought this to the provider’s attention; however, on our return visit to the service we found that this had occurred again with no medical advice being sought. This placed people at risk of becoming extremely unwell or even death.

For a person who had been prescribed nicotine patches we found they had commenced smoking again at the same time staff were applying nicotine patches. The provider had failed assess this risk and seek medical advice. The use of nicotine patches and smoking poses a risk of harm due to the person receiving too much nicotine.

It was difficult to ascertain if time-sensitive medicines, such as those which were required to be given prior to food, were being given at the appropriate times, as service users’ medication administration records (MARs) did not have exact times of administration recorded on them. This was brought to the provider’s attention who told us they would address this issue.

Overall, medicines were stored correctly and the actual stock of most medicines we checked matched the expected stock. However, where medication errors had occurred these had not always been adequately investigated and actions taken to reduce the risk of recurrence. Where the actual stock of 1 person’s medicines did not tally with the expected stock, and they appeared to have been given too little medicine. This was not escalated as per the provider’s policy and medical advice was not sought. This placed the person at risk of harm from experiencing increased symptoms of their diagnosed condition for which the medicine was prescribed.

Most people and relatives we spoke with had no concerns in relation to the support people had with their medicines. However, 1 relative raised a concern in relation to the lack of pain relief which they had requested.

Although we found concerns in relation the safe management of medicines, we found no evidence of harm being caused to people.