Archived: Bright Brains Global Limited

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

The service was in breach of legal regulation in relation to the safety of people’s care and treatment and medicines were not always managed safely. People were not always protected against the risk of abuse and there were not enough appropriately trained and assessed as competent staff deployed to support people.

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 listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. There was no analysis of people’s behaviours of distress to look for trends and themes to reduce further risks. Incidents were not always recorded and where they were, there was not sufficient detail in order to determine how the incident occurred or why. For example, where staff had recorded injuries to people on body maps. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. Whilst there was some evidence of debriefs with staff after incidents however, these were infrequent.

The provider did not 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. We noted people had hospital passports however, they did not important information for health care professions should the person need to go to hospital. For example, 1 person’s hospital passport had not been reviewed since 2022 and did not include that it was crucial for the ‘meal’ routine to be maintained. It stated the person did not like using a shower, yet the person frequently used the shower to help them to calm down when in distress. When people moved into their home, there was a lack of planning to ensure a smooth transition. The plan should involve the person, their family, staff, and relevant professionals, ensuring a collaborative approach. We found this was not happening for most people and some relatives told us they were not involved. We found people were not gradually introduced to their new home, allowing them time to adjust and become comfortable.

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.

Relatives did feedback that they felt their loved ones were safe with staff. However, we identified multiple incidents of alleged abuse that harm the provider and staff had not raised with the local authority safeguarding team. The local authority safeguarding team told us they should have been made aware of these instances. Staff told us they would report any safeguarding concerns to their line manager and escalate this if no action was taken. However, we found they were not always doing this when issue arose.

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. One person was cared for in bed, however there were no risk assessments in place or guidance for staff on how best to support the person. This included but not limited to, the risk of pressure ulcers, oral hygiene, moving and handling, dehydration and malnutrition and catheter care. One health care professional fed back staff were not safely moving the person (who had developed a pressure ulcer) in bed or taking action to help reduce the risk of the pressure ulcer deteriorating.

There was a lack of positive behaviour support plans in place with information on what may distress people or how staff needed to respond when the person was directing their anxiety towards people, staff and others. Where people were at risk of constipation, there was a lack of risk assessments in place. We identified several instances where a person had not opened their bowels for a period of time, yet there was no evidence this had been escalated to a health professional. This was despite staff telling us they would need to do this after 1 day. This placed people at further risk of constipation.

The provider did not always detect and control potential risks in the care environment. We found the front door was permanently locked from the inside in one home when everyone was at home and could only be unlocked with a key. This could cause potential delays should there be a fire. The personal evacuation plans for people were not kept in the fire grab bag which again meant this could cause unnecessary delays if the emergency services could not access these quickly.

One person was at risk of harming themselves and others as they had a history of breaking the objects. One relative told us, “(Person) broke the TV recently, I told them (staff) they had to raise it towards the ceiling so (person) can’t touch it. The staff told me that the landlord told us we can’t make adaptations. I find that a bit difficult when they’re not adapting to that environment, it should be high risk. However, we saw from people’s tenancy agreements that the provider is also the landlord so they could have taken action to address this.

However, there were health and safety audits taking place each week where other areas of the maintenance of the homes were addressed.

The provider did not make sure there were enough qualified, skilled and experienced staff. One person was required to have 2 staff with them when they were being repositioned in bed and when they received personal care. However, for the majority of the time only 1 staff was present aside from first thing in the morning. One health care professional told us, “It’s not ideal just one [staff] repositioning [person], they really need two (staff).”

In 1 supported living home where 3 people lived, there required to be 4 staff during the day based on the funding arrangements from the local authority. However, rotas for February 2025 and March 2025 showed more often than not there were only 2 staff scheduled to work. When we attended the home on the second assessment site visit, all 3 people were home, but there was only 2 staff on duty. In the other supported living home, there required to be 3 staff however the rotas showed there were frequently only 2 staff rostered. This placed people and staff at risk of harm. We asked the provider who was also the registered manager to address this.

Staff were often working 2 back-to-back 12-hour shifts both during the day and at night. There were no systems in place for staff to have formal breaks during their shifts. Staff worked in a high-pressure environment, supporting people with high levels of anxiety and care needs. The lack of formal breaks and long working hours were concerning, as staff did not have adequate time to rest and decompress.

Whilst we saw evidence the majority of staff had received mandatory training, there was 1 member of staff who was supporting a person who was cared for in bed. They did not appear on any training records, so we were not assured they were appropriately trained and assessed as competent to provide care. Although staff told us they received training in how to safely restrain a person if they were having distressed behaviours, the provider was unable to give us evidence of this.

When new staff started work, whilst we saw they were assessed as competent before they delivered care, the forms completed by their manager did not relate to the care they were going to be providing. All the competency forms related to care at home whilst the majority of the staff were providing care to people in supported living settings. None of the observed competency forms stated where the member of staff was observed to be working. One relative told us, “I feel like they [staff] don’t understand [person’s] needs.”

The provider did not always assess or manage the risk of infection. Whilst the homes we visited were generally clean and tidy, we found people in 1 home did not have access to toilet roll as staff locked this away. We noted on second assessment site visit that the toilet had faeces in it. There was also reference to this house in staff meeting minutes, where staff noted that 1 person in this house needed support when using the toilet. We asked staff to address this.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. In 1 person’s home, staff were administering all of the person’s medicines. However, there was no medicine administration record (MAR) in place. It is a working document used to keep an accurate record of the type of medicine and the time it is administered. We found this was not done. In addition, a health care professional told us staff were not giving the person with sufficient ‘as and when’ pain relief. They told us, “(Staff member) was only giving [person] 1 tablet every morning, which was having no effect.”

We found the ‘as and when’ medicines protocols for people lacked detail around when staff needed to administer medicines to reduce their anxiety. We noted staff had given this medicine on 8 occasions in November 2024 and also on 2 occasions in January 2025 to a person. Staff were not recording why this medicine was being given. This meant the provider could not be assured this medicine was required or what other steps staff took before they resorted to this. There were also multiple occasions where staff were handwriting prescriptions on a MAR without any staff signing this to confirm it was accurate as per their medicine policy.