Brooklands Homecare Ltd - Edenbridge

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 assurance about safety. There was an increased risk that people could be harmed.

The service was in continued breach of legal regulation in relation to people’s safe care and treatment, including the way people’s medicines were managed.

This service scored 56 (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. 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.

Although people gave examples of how staff had supported them following falls, the provider did not have a fully embedded learning culture. Incidents and accidents had not always been reviewed in a timely manner including any action that had been taken to help prevent future risk of re-occurrence. For example, people who had experienced falls had not had their risks or planned care reviewed so the provider could assure themselves risks were being effectively mitigated. Despite this, we did not find people had experienced any repeated incidents or harm.

Staff described sharing information through group chats and briefings; however, we found that not all incidents were escalated to the office in a timely manner to support risk mitigation and oversight. For example, several missed or late medicines were not treated as medication errors and were not escalated in line with the provider’s own policy, which states that all omissions must be reported and investigated.

There was a lack of regular staff meetings which reduced opportunities for systematic learning across the team.

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 and relatives confirmed assessments were completed before care began. A person said, “They did an assessment with myself and [my relative]. They also came a couple of times after that.” Staff could describe the process for new packages, including care plan development and risk assessment. The service worked with external professionals such as district nurses and GPs when referrals were required.

However, people’s care records had not always been updated in a timely manner to ensure their records reflected their current care needs. Some documentation to support safe transitions between services such as hospital passports contained out-of-date information. The provider took action immediately to update these when we raised it with them. Despite this, feedback from a health and social care professional was that there was good collaborative working between themselves and the service with clear communication.

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.

People and relatives consistently told us they felt safe. A person said, “I am very safe and very, very happy with the service.” Staff understood safeguarding and described appropriate actions, stating they would report concerns immediately and document them. Staff training in safeguarding was in place. The safeguarding log showed a low number of concerns. Feedback from 1 health and social care professional was that the service escalated any potential safeguarding concerns to relevant professionals as required.

The provider did not work well with people to understand and manage risks.

Not all risks for people had been assessed such as risk of falls, constipation and skin integrity risks. Not all people’s individual health conditions had been risk assessed such as people with breathing difficulties or at risk of seizures. There was not always guidance in place for staff to follow in relation to people’s risks and their care needs such as signs of deterioration or actions for staff to take to escalate or mitigate risks. There were widespread shortfalls in the documentation to support people’s care planning, and people’s care notes lacked detail to demonstrate risks were managed or reviewed. We found no evidence of harm; there was a long-standing staff team who understood people’s needs in practice which reduced people’s risk of harm. However, the shortfalls in people’s care records meant people were at potential risk of harm when receiving support from new staff or those who were not part of their regular team.

Despite this, people often felt involved and informed about their care.

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

People were supported within their own homes and most relatives reported staff left the environment safe and tidy. A person told us, “[Staff] clean up after themselves.” Staff described checking for hazards such as trip risks and moving items with consent to reduce risk to people. Environmental risks were documented in people’s care records. There was evidence of home adaptations being sought through occupational therapists when needed to ensure people had access to equipment to support them safely. People’s care records contained guidance to support staff to use equipment safely. A relative said, “We have a hoist, [Person’s name] feels safe in the hoist. [Staff] seem to be trained.” Staff told us, “I do hoist work. I have had training and there is always 2 of us.” Overall, people told us they felt safe at home and staff acted respectfully within their environment.

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.

People and relatives gave us positive feedback about staffing. Most people felt staff arrived on time. Following a recent survey in March 2026, the results showed an improvement in staffing compared to the survey results from December 2025 which showed some reports of missed or late calls without communication. Staff told us rotas and staffing levels were mostly stable.

The provider was behind their schedule on reviewing people’s paper care notes kept in their home. This was the provider’s system for monitoring that calls took place on time and for the required duration. Although people continued to feel well supported, gaps in management oversight reduced assurance of safe staffing.

Staff had not always been supported by the provider to develop skills and knowledge. The training matrix showed staff were supported to complete mandatory training, however staff training was limited. Staff had not received any additional training to meet specific health needs for people such as around diabetes or catheters. We fed this back to the provider and will follow this up at our next inspection.

We found most staff had been recruited safely. We found gaps in 1 staff members employment history which had not been explored. The provider took action immediately to contact the person for a written explanation. The provider’s systems had not supported them to ensure they obtained a full employment history, however the provider added this to their service action plan following the inspection. We will check this at our next inspection.

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 and relatives confirmed staff used gloves, aprons and maintained good hygiene. A relative told us, “Yes, they do all that (infection control).” People reported staff maintained clean environments and followed appropriate precautions during illness, with 1 person saying staff were “excellent” when supporting them during COVID‑19. People’s records of care demonstrated times where staff noticed signs of infection for people and took action to escalate these concerns.

Staff described accessing personal protective equipment (PPE) from the office, used correct disposal methods, and followed hand hygiene routines. Staff also described checking dates on people’s food to ensure the risk of infection was reduced. Staff had completed infection control training.

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

Medicines were not managed safely. Staff sometimes prepared and left medicines out for people to take later. We found for 1 person their risk assessment specifically stated not to leave medicines but, staff told us and records demonstrated, the person’s medicines were prepared and left out to take. This practice was contrary to the provider’s own policy and National Institute for Health and Care Excellence (NICE) guidance and placed the person at risk of not receiving their prescribed medicines.

A person was regularly administered some of their medicines at the wrong time. Tea-time and evening medicines were combined without consultation with relevant healthcare professionals. We raised this with the provider who sought assurance this was safe to do and would not have harmed the person. Although the person did not come to harm the provider had failed to ensure the person received their medicines as prescribed and had not assured themselves the person was not placed at risk of harm. The same person had been given medicines at the incorrect time following a missed call. Their morning medicine was given at lunch time and their lunch time medicine was omitted instead meaning the person missed 1 dose of 1 of their medicines. This decision was not made with consultation from relevant healthcare professionals to decide the best course of action. This placed the person at risk of harm.

Another person had been prescribed 2 different doses for 1 of their medicines, a dose was administered for the majority of the month but there was a period of 4 days when an alternate dose was administered. It was not clear what dose the person should have received. We asked the provider for assurance around the changes, but information sent did not provide clarity. The provider could not be assured the person had received the correct dose of medicine.

There were concerns with recording practices on medicine administration records (MAR). We reviewed MAR charts for 4 people and found missing signatures and contradictory codes. MAR charts were inconsistently completed and did not meet NICE guidelines, for example, not all medicines included the formulation, strength or frequency. Some medicines did not have special instructions recorded on the MAR such as when or how the medicine should be given or maximum doses. There was a risk people would not receive their correct medicine safely.

‘As Required’ (PRN) medicines lacked protocols, these are important to help staff know when and how to give PRN medicines and what for. Some people received support to administer prescribed creams, the providers policy was for a topical MAR to be in place however they had not followed their own policy.

The providers records indicated some staff lacked up‑to‑date medicines competency assessments; the provider told us they would take action to bring these up to date.

Overall, medicines management required significant improvement due to the systemic issues identified to ensure safe and person‑centred practice. The provider took onboard feedback given during the inspection and had begun to complete a full review of all people’s medicines. They sent communication to staff about safe medicine administration processes.