Brook Lodge 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment 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 people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment. 

This service scored 53 (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 and positive 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.

Effective systems, processes, and tools to support safe care had not been fully implemented at the service. Although accidents and incidents were recorded and analysed by the provider, shortfalls remained in relation to the use of Antecedent Behaviour Consequence chart (ABC) charts, which are used to understand and respond to distressed behaviour, particularly for people living with dementia. Both paper‑based and electronic systems were in use, and these did not consistently align. This meant not all information was being captured to identify any themes or trends.

Previous concerns relating to people’s safety arising from these types of incidents had been identified. However, we were not assured the provider had sufficient oversight or governance arrangements in place to effectively monitor, analyse, and reduce these risks.

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.

Although some processes were in place to support people during changes in their care, these were not used consistently. Information was not always accurately shared or updated when people’s needs changed, which increased the risk of unmet needs or inappropriate care being provided.

Transitions between staff teams and shifts were not always supported by robust handover processes. Inconsistencies in record‑keeping, including the use of both paper and electronic systems, meant staff did not always have access to clear and up‑to‑date information. This limited the provider’s ability to ensure people received safe, person‑centred care at all times.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

Although safeguarding policies and procedures were in place, these were not consistently followed in practice. Staff did not always recognise or escalate concerns appropriately, and there was a lack of consistent understanding about when incidents or patterns of behaviour should be reported as safeguarding concerns.

For example, 1 incident was recorded where a person was found at the top of the stairs. The person was at risk of falling and this increased their risk of significant injury if they were to fall Although this was recorded on the electronic care planning system and the person did not come to harm, there was no corresponding incident form completed, and no investigation undertaken. This meant we were not assured all reasonable measures had been taken to identify potential risks, understand how the incident occurred, or reduce the likelihood of similar incidents happening again.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that most applications were appropriate and 1 was discussed which the provider subsequently withdrew.

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

Although risk assessments were in place, they were not consistently reviewed or updated when people’s needs changed. There was limited evidence to show people, or where appropriate their relatives or representatives, were meaningfully involved in reviewing risks or agreeing how these should be managed. For example, information about people’s mobility was inconsistent across different sections of their care plans. There was no specific individual risk assessments related to wheelchair use.

Monitoring and risk management practices were not always delivered in line with agreed guidance. Skin integrity monitoring charts did not consistently reflect the instructions set out in care plans, and catheter care risk assessments lacked sufficient detail to clearly guide staff practice.

Where people experienced distressed reactions or incidents that increased their level of risk, information was not consistently used to support people to understand what was happening or to agree strategies to reduce future risks. Inconsistent use of tools such as ABC charts limited opportunities to identify triggers, reflect with people on their preferences, and develop preventative approaches that supported positive risk‑taking and promoted independence.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental checks were in place and completed regularly. The provider told us they were arranging replacement fire doors as they were aware there were issues with the current fire doors.

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 met people’s individual needs.

During the inspection, observations did not identify immediate concerns regarding staffing levels. However, staff told us there were occasions when a high number of temporary staff were used. This affected continuity of care, as temporary staff did not always know people well, including their preferences, routines, and risks.

People and relatives gave us mixed feedback about staffing levels. A relative told us, “Sometimes there are not enough staff. I feel there isn’t always sufficient staff in the communal rooms. For example, a resident will ask for assistance, and they can wait quite a while before they receive it.” Another relative added, “I think they are understaffed and when they have staff, they are not always well directed by managers.”

Other feedback was more positive. A person told us, “Staff are kind, they come when I buzz. I have a pendant on my neck I use to buzz staff. If I want something I ask for it and if they have it, I can have it." Another relative told us the service was trying to address the issue of insufficient staff by employing more staff.

Staff feedback was also mixed about staffing. A staff member told us, “There is not enough staff, a lot of pressure on staff, residents continually waiting for us to support them. Not allowed to say we are short staffed. I do days and nights.” Another staff member said, “The regular staff work hard to minimise impact, but the care is compromised as [temporary] staff do not know residents. It can impact on people.” Other staff added, “Staffing is usually okay, but when short, it can reduce time spent with residents, especially for emotional support” and “They are now using [temporary staff]. They are covering now.”

Staff feedback regarding support and supervision was also mixed. Some staff described positive experiences in their roles, while others raised concerns about the frequency and consistency of supervision and support. This limited the provider’s ability to effectivelymonitor staff practice, identify development needs, and ensure consistent standards of care.

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.

Where concerns arose, these were promptly recognised and managed to prevent the spread of infection, including the implementation of suitable control measures. During our visit we found the service on the whole to be clean and odour free.

One relative expressed concerns their family member’s room was not being cleaned. The provider told us this person had refused access to staff and other agencies were involved to try to better support this person who had expressed they wanted to move.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified gaps in stock control and medicines reconciliation, with recorded quantities not consistently matching actual stock held. This meant there was limited assurance medicines were being managed safely. Some medicines, including those requiring particular storage, remained in stock beyond their recommended timeframes. Although these had not been administered, the risk remained while they were still available. Dates of opening were not consistently recorded or monitored in line with recognised guidance, and the provider’s policy for checking these medicines had not always been followed.

Arrangements for the use of ‘as required’ (PRN) medicines were not always clear or person-centred. Protocols were missing or required review, and records did not consistently demonstrate medicines were administered in response to identified need. In particular, records relating to PRN medicines used for behaviour did not align with behaviour monitoring documentation, meaning it was not always possible to evidence their use was appropriate, proportionate and in line with best practice.

The provider told us they had taken action to address the issues identified and had implemented more robust monitoring of medicines systems including the use of PRN medicines, however this process needed embedding.