Brooklands Homecare Ltd

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 good. 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 legal regulation in relation to people’s safe care and treatment, the way people’s medicines were managed, and staff training and supervision.

This service scored 38 (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. Managers did not always respond to concerns about safety events. Lessons were not always learnt to continually identify and embed good practice. Staff reported health concerns such as falls to the branch manager which were appropriately escalated to relevant health care teams. However, risks were not always reviewed and mitigated to prevent reoccurrences.

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. A person had spent a period of 8 weeks away from the service due to a change in their needs, upon recommencement of the package of care, managers had not arranged a reassessment of their needs. However, the branch manager had kept in touch with them over the weeks and the person had made improvements. The registered manager told us they routinely contacted hospital wards when people were admitted but a full reassessment of needs was not always conducted.

The provider did not have processes in place to concentrate on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not have processes in place to share concerns quickly and appropriately.

People told us they felt safe with staff and did not express any concerns. However, we spoke with staff around their knowledge of safeguarding and how they would respond if they had concerns about a person. Staff told us they would report concerns to the branch manager but did not demonstrate an understanding of where to escalate their concerns to external agencies if needed. A staff member said, “I would call [branch manager] or whoever in the office if I had a concern. If I couldn't speak to [branch manager] (if they were implicated), I would speak to [office staff], or head office, [registered manager] the owner. I know there is one (safeguarding policy), it's in the office. I can't remember the last time I read it.” Another told us, “If any physical abuse evident I would report to the office, if necessary 999.” We received feedback from 5 staff, all except 1 were not aware to report concerns to the local authority safeguarding team. The provider’s policy was not readily accessible to care staff; the branch manager told us staff would attend the office to access it, or the policy could be emailed to them. The staff handbook did not contain details of how to raise safeguarding concerns. The provider’s policy was overdue for review in September 2023 and did not contain contact details of the local authority, there was a link to a website for reporting concerns, but the link was broken. Staff received online training in respect of safeguarding people; however, their knowledge and understanding was not assessed.

The provider did not work well with people to understand and manage risks. Whilst staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them, risk assessments and associated care plans had not been completed. Staff and managers completed a 1-2 page ‘information sheet’ in lieu of care plans, they also completed a basic ‘risk assessment form’. The information sheets included a brief overview of the person, listed some medical conditions, equipment and directed staff how to get to the person’s properties. There was no detail or guidance to staff about how to support people with their conditions. The risk assessment form listed potential risks, however, where risks had been identified, they had not been explored and mitigated. For example, where a falls risk or history had been highlighted, the risk assessment forms guided staff and managers to complete a falls risk assessment. This had not been done for 3 people we reviewed, 2 of which continued to experience falls. People’s information sheets were not kept up to date with their changing needs. We reviewed people’s daily care notes, medicine records and communication logs and found people has been diagnosed with health conditions that had not been included on their information sheets. For example, a person was prescribed medicines for diabetes, which was not included and there had been no risk assessment conducted. The branch manager told us and provided evidence that staff were updated about people’s needs through their Whatsapp group and emails; however, information and detail was still lacking.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment and facilities supported the delivery of safe care. Some people were supported with various pieces of equipment to move around their homes. An occupational therapist (OT) had been involved with a person and had trialled various types of equipment to aid their mobility and promote their safety. Although the OT had left instructions at the person’s home, staff and managers had not assessed the risks and had not fully updated the person’s care records to reflect the support needed. Another person’s risk assessment form listed some equipment; however, we found in daily care notes that they used a stairlift, which had not been included in the information sheet and was not risk assessed.

The provider did not make sure there were enough skilled and experienced staff. They did not make sure staff received effective support, supervision and development. Due to staff absences, a person who had been away from the service for a period of respite was unable to restart their package of care for 2 weeks. The person’s relative had sourced a private carer until Brooklands Homecare were able to recommence the support. Staff were not always recruited safely; a staff member had commenced duties without the provider’s required checks in place. The branch manager told us staff had been recommended to them which they felt reduced any risks. Staff had completed online training which the provider had deemed mandatory. However, staff were supporting people with a range of conditions including diabetes and Parkinson’s disease and had not received any training in those areas. Induction training for new staff included shadow opportunities with other care staff, a form was completed to confirm shadowing had happened but did not include what tasks new staff had been shown. Competency assessments had not been completed to ensure staff were performing in line with safety standards. Staff did not receive spot checks or supervisions; they were offered a yearly appraisal and annual observations. The observation sheets did not detail what tasks were observed. We saw a staff member had not been observed since April 2024 and 2 others since May 2024. The branch manager told us they were close to the staffing team and spoke with them on a regular basis and as they personally knew them they did not feel additional supervision was required.

The provider assessed and managed the risk of infection. People told us staff respected their property and helped them keep their homes clean. Staff had received training in food hygiene, infection prevention and control and had been provided with stocks of personal protective equipment (PPE). A relative told us staff wore additional PPE to respect their own health needs, they said, “[Staff member] is very tidy and very helpful, everything is left clean, towels are hung up to dry. [Staff member] actually wears a mask, gloves and apron because of my immune system.” A staff member told us, “I wear the PPE provided.”

The provider did not make sure that medicines and treatments were safe. Processes were not in place to ensure staff received clear guidance to administer medicines safely. A person was prescribed Paracetamol on a ‘when required’ basis, their medicine administration record (MAR) charts and information sheet did not specify times for administration. The branch manager told us staff were aware to administer Paracetamol at the start of each visit to ensure the appropriate intervals between doses. However, a staff member did not echo the same advice, this left the person at risk of potential medicine overdose. Staff and managers had not conducted an assessment to ascertain the level of support people required and to enable a medicine care plan to be written. Not all medicines were included in people’s information sheets and MAR charts; a person’s prescribed creams had not been listed. There had been no assessment conducted or guidance to staff about the potential fire risks regarding the use of the paraffin-based creams. Managers did not follow their own policies to assess high risk medicines such as blood thinners; this could leave people at potential risk of harm if injured. Staff received online medicines training but there had been no competency assessment conducted to ascertain their safety and capability to administer medicines.