Brendoncare St Giles View

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. This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

People and relatives spoken with did not have any concerns about raising any issues if needed. The provider’s records showed people and relatives had been informed of notifiable safety incidents as required under the Duty of Candour.

Staff spoken with knew how to escalate concerns and where and how to record any safety incidents. Staff said they were updated following incidents, and any learning from them was shared. Staff had access to relevant policies and procedures to manage safety events.

Leaders told us the provider had a new incident/safeguarding reporting system, which enabled detailed reporting of incidents. We saw leaders reviewed and risk rated the incidents and ensured any required actions were completed. Leaders analysed incidents monthly for any trends and lessons, which the provider then shared across the organisation through their monthly clinical bulletin. Staff were able to learn from incidents across the provider’s services and the sharing of learning from national safety events.

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.

People were required to have a full pre-admission assessment before they were admitted to the home. We spoke with nurses and care staff and were assured they understood the care needs of newly admitted people.

The provider had processes to ensure staff were updated when people transitioned into and out of the service. There were daily oversight meetings which included all heads of departments and the clinical team. People confirmed information was shared appropriately.

We saw when a person experienced a poor hospital discharge, an incident was raised to enable staff to identify what had gone wrong and to identify any learning to reduce the risk of repetition.

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.

Staff spoken with understood their role in preventing abuse and the actions to take. Staff completed relevant training and had access to the provider’s safeguarding policies and procedures. The provider had processes to ensure safeguarding incidents were thoroughly investigated and reviewed. Partner agencies told us the provider had taken appropriate actions when safeguarding alerts had been made. All safeguarding incidents were reported to the provider’s safeguarding committee on a quarterly basis. The committee included a relative representative, to enrich the committees understanding of safeguarding from people’s experience.

People said they felt safe living at the service. A person shared information with us about a potential safeguarding incident, which we reported to the provider. We saw leaders immediately followed their safeguarding policies and procedures and took the relevant actions to ensure the person’s safety.

Staff had submitted Deprivation of Liberty Safeguards (DoLS) applications as required for people who were subject to restrictions upon their freedoms which amounted to a deprivation of their liberty, where they lacked capacity to consent to them. People’s records contained an alert on the front page to inform staff if a person had a DoLS in place.

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 had a range of risk assessments. People’s generic risks had been assessed, such as from falling and skin integrity, as well as individual risks related to their personal needs. Where risks were identified, plans were in place to manage them. People’s records showed they had been involved with decisions wherever possible, about how they wanted risks to them to be managed. A person’s care plan noted they wanted bed rails to be used, as they made them feel safer. People told us staff ensured they had any equipment they required, which they were reminded to use.

Staff felt risks were managed well and we saw they had access to guidance about how to manage risks to people, such as from falling. Leaders told us from their incident analysis they had identified a trend of an increase of incidents involving people who expressed their needs and emotions through their behaviours. The provider’s new dementia lead nurse had recently provided staff with additional face to face dementia training workshops and was also supporting staff to review people’s care plans. The provider was also looking at providing further training for staff in positive behaviour support to further develop their skills and knowledge. People had personal behaviour support plans where required, which guided staff about the possible triggers for people’s behaviours and how to support the person.

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

We saw the building was secure, however the short distance between the lift entrance and the front door to the car park meant that if the reception was not staffed the main entrance was locked to mitigate the risk of people leaving. We observed on 1 occasion the reception area was not staffed and the front door was open to facilitate a delivery. Although vulnerable people were not present, this was fedback to the provider for them to risk assess this arrangement. There was signage both in the reception area and the lift to alert visitors to be aware of people entering the lift on each unit. We also noted on the first floor a broken door lock which led onto a patio. We raised this risk with the provider and the lock was repaired immediately.

The provider supplied evidence which showed the design of the building reflected legislative requirements and good practice design principles for spaces for people living with dementia.

We saw communal areas such as the café, multifunction room and hairdressers were located on the ground floor and that the accommodation was on the upper floors, with the dementia unit on the top floor. People’s access to all floors including the communal areas and garden was via 1 keypad-controlled lift. Staff had access to a second lift and the stairs. People whom we saw use the communal areas and garden were dependent on staff to allow access. Some people commented about their lack of easy access to the garden. Their feedback included, “I’d like to go in the garden, but they don’t often take me” and “I don’t like to be shut in. I haven’t been here long, so I haven’t been in the garden.” The provider told us people’s capacity to have the lift code was assessed upon admission and 5 people had chosen to have it currently, whilst a further 2 preferred to be accompanied by staff.

We noted the layout and décor were similar on each of the accommodation floors and lacked sufficient visual information for people living with dementia to orientate themselves. There was limited accessible signage for people to either find their way around their floor or to identify their bedroom. The signage was identical on each floor, although the top floor accommodated people living with dementia.

The provider was fully aware of the issues with the building design, particularly in relation to the experiences of people living with dementia and told us they had a meeting arranged with the landlord’s dementia specialist for October 2025 to determine what improvements could be made. After the inspection, the provider also supplied details of their proposals within their interim dementia plan, which included improved signage and theming corridors to aid orientation.

People’s care plans lacked information about the correct setting for their air mattress, where they used one. We checked 3 and found they were not set correctly for the person’s weight. Maintenance staff completed monthly safety checks on air mattresses, so there was a risk this may not have been identified promptly. We spoke to the provider who acted immediately and put in place new processes to ensure they were checked daily and updated people’s care plans. People at risk of pressure damage were also regularly re-positioned by staff, which had mitigated this risk.

The provider ensured required safety checks on the building in relation to gas, electrical, fire and water safety and other equipment safety checks were completed. We saw adapted equipment was in place for people where required. People had been provided with any equipment they needed to manage identified risks to them. For example, profile beds, crash mattresses, pressure cushions and mobility aids. The corridors were wide and clutter free with good lighting levels. People had access to a range of seating areas on each floor. The upper floors had patios and balconies which people could access.

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. Evidence of pre-employment checks was not always complete for all staff who had transferred employment from another provider.

The provider used a staffing tool as a guide to determine staffing levels on each of the 3 floors and some staff ‘floated’ between floors to offer additional support. People and relatives provided mixed feedback on staffing numbers, but no one said their needs were not met. We observed there were enough staff to meet people’s needs and that their care was not rushed.

The service when built had replaced two previous homes, and some of the staff team had transferred their employment (TUPED), when they joined the service. We identified records for 1 of these staff did not contain evidence of all their required pre-employment checks. When we brought this to the provider’s attention, they immediately checked the records of other staff who had been TUPED for any gaps. Shortly after the site visits, the provider supplied evidence that where they had identified any gaps, this information had now been obtained. However, the provider had robust recruitment checks for staff they had recruited since opening, including agency staff and all required pre-employment checks had been completed as required.

Staff told us and records confirmed they all underwent a specific induction for their role, a probationary period and regular supervisions and training. Newly qualified nurses commenced a preceptorship to support them through their transition from student to registered nurse. Nurses were well supported with their professional re-validation. Senior staff were offered opportunities to develop more advanced skills through the Care Home Assistant Practitioner’s (CHAP’s) course. Training for which was due to commence in November 2025.

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.

People told us the service was clean and said staff wore personal protective equipment (PPE). We saw the service and equipment was clean and there were plentiful supplies of PPE and cleaning products which were stored securely.

Staff had completed infection control training and their arms were bare below the elbow. Staff understood how to barrier nurse if people had an infection and had access to relevant infection control guidance which they followed. The provider had processes in place to ensure infection control processes were audited.

However, we noted some cleaning records required review to ensure staff completed them thoroughly. This was shared with the provider during the inspection, and they acted to address this.

The service did not always make sure that medicines and treatments were safe and met people’s needs. Although, we found no evidence that people within the service were placed at harm, changes could be made to improve the safe management of medicines.

People were treated with care and compassion when receiving their medicines, which was undertaken in a way that met their individual needs.

We saw that when people needed to be given their medicines at a specific time, there was a process in place to ensure that the prescribed instructions were followed, meaning that people got these medicines as intended. There was no indication of medicines shortages, indicating that ordering processes were effective to ensure people’s medicines were available to them when they needed them. There was no evidence of excessive administration of medicines to manage emotions and behaviours. People approaching the end of their life, prescribed anticipatory (‘just in case’) medicines had the appropriate administration instructions in place.

However, records, protocols and care plans to support safe management of medicines did not always contain enough information to guide staff or give assurance that medicines were managed appropriately.

Protocols for the administration of ‘when required’ (PRN) medicines in some cases lacked detail to support staff in the appropriate administration of medicines. For instance, whether to administer one or two tablets, or when to introduce a second laxative for constipation if multiple were prescribed. In addition, the reason for administering and outcome were not always recorded.

Care plans were in place but lacked important details. For example, one care plan for a person with diabetes did not include target blood glucose levels or instructions for managing and changing the blood glucose monitoring sensor. This meant uncontrolled blood glucose levels may not be recognised and managed.

Records for people with swallowing difficulties and therefore requiring supplements to thicken drinks were not consistently recorded with the fluid consistency prepared. It was unclear if drinks were being thickened correctly. For people prescribed topical creams, the application was recorded only on their daily notes and not on their medicine administration records. It was therefore uncertain as to whether these were being applied as prescribed and according to people’s specific care needs.

Policies were in place detailing responsibilities of the provider and staff. However, these lacked detail and clarity regarding how medicines related processes were to be undertaken and of staff training requirements. This caused inconsistent practice which was not in line with best practice. For instance, the process for managing medicines when people were away from the home (on social leave), did not reflect national guidance.

Audits were carried out and actions were mostly identified. However, actions were not always assigned to specific staff members or given clear completion dates. As a result, some were not followed up and remained incomplete.