Briar House

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 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.

This service scored 50 (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.

However, lessons were not always learnt to continually identify and embed good practice.

Accident and incidents were recorded and where needed referrals were made to the local authority. However, improvements were needed to the recording of the actions taken to mitigate risks of future similar incidents occurring.

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.

Pre-admission assessments were completed to ensure that people’s care needs could be met by the service. Referrals were completed for people in relation to concerns or changes to their needs related to swallowing issues, mobility and wound management. An emergency pack, containing essential care and health information was in place in the event of an emergency.

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.

Accidents and incidents were well documented and frequently reviewed by the manager. Where appropriate safeguarding concerns were reported to the local authority safeguarding team. If needed, actions were taken to reduce the risk of future occurrences.

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

We found that not all risk assessments which were needed were in place, for example 1 person who had recorded food allergies did not have a risk assessment in place. This put them at risk of experiencing an allergic reaction and a delay in medical attention being sought if they did so.

Risk assessments had been completed for other care and support needs such as choking, mobility and falls. However, choking risk assessments for people receiving a texture modified diet did not include this information and recorded their risk of 0. This did not actively reflect their needs and increased the risk of them receiving the incorrect diet.

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

The service had systems in place to review the safety of the environment; however, we found that these were not always effective in identifying areas of concern.

We found that gas safety checks on the laundry equipment were overdue and last completed in March 2025. The laundry room did not have a carbon monoxide detector in place so a leak would not have been identified by the service.

We found that the risk assessment in place for the deep fat fryer had not been reviewed since 2023 and that the kitchen staff were unaware that a risk assessment was in place.

Paperwork in the home relating to fire safety checks was not always up to date and the kitchen suppression safety check was overdue. On the first visit we found high risk items such as toiletries and tubs of prescribed thickener powder accessible in people’s bedrooms and bathrooms.

People had detailed Personal Emergency Evacuation Plans (PEEPs) in place.

These concerns were raised to the service and we requested reassurances. The service took actions to address our concerns.

The provider did not always make sure that staff were qualified, skilled and experienced.

We found that staffing levels were well planned and maintained. Staff told us that they felt they had enough time to support people.

Staff had received appropriate training; however, competency assessments had only been completed for medicines, handwashing and Personal Protective Equipment (PPE) use. The competency assessments viewed for medicines showed that several had last been completed in 2024 and were overdue.

Fire drills were being completed monthly, however, these recorded concerns and stated that staff required further training which had not been actioned.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The environment was observed to be clean and cleaning schedules were in place. However, we found that paint was coming off in some areas, scuffs and scratches on skirting boards and doors, in some place's deep gouges were found in the wall plaster. This meant that some areas were difficult to effectively clean.

One staff member told us, “The maintenance of the home affects the cleanliness, not everywhere can be cleaned properly and even when it is clean, it doesn’t look like it.”

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

During the first visit we found that when required medication (PRN) charts were not always in place. Medicines stock levels recorded on people’s Medication Administration Records (MAR) charts did not always match the number of medicines in the home. Not all people’s medication allergies had been recorded on their MAR charts. This was given as feedback to the manager at the time and had been rectified; however, we found the same concerns relating to PRN charts and allergies on a follow up visit, after the medicines cycle had changed.

One person was prescribed a medicine covertly if needed, instructions on how to administer this were not in place. Although the person did not currently require the medicine to be administered covertly the lack of instruction could mean that if it was required staff may administer it incorrectly.