Brantwood Hall 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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained 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 safe care and treatment; staffing and good governance.

This service scored 34 (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.

Systems and processes were not effective in identifying shortfalls, capturing lessons learnt, or driving improvement. Oversight of accidents and incidents was not robust and some records contained gaps. One incident involving a person’s injury had not been recorded on an accident form or reported to the local authority and CQC. The provider failed to learn lessons and take appropriate action to address concerns identified during the previous assessment to improve the quality and safety of the service.

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.

Processes were in place to support admissions into the service. However, there had been no admissions since our previous assessment. People were supported to access GP's and other medical services. However, gaps in some people’s records and a lack of robust service oversight remained, which meant we could not be assured information sharing was accurate and consistent to support people’s safety.

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.

Oversight of safeguarding concerns was insufficient. The provider had not taken appropriate action in response to a safeguarding concern raised at the previous assessment in relation to 1 person. The person continued to have their needs neglected. We asked the provider again to raise a safeguarding alert to the Local Authority in relation to this. In addition, 1 serious injury to a person had not been notified to CQC.

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. Oversight of people’s DoLS was not robust. Three people’s applications had not been notified to CQC. This had not been identified by the provider prior to the assessment.

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.

Oversight was ineffective in ensuring the safe management of risks to people. There was a lack of oversight and monitoring of people’s skin integrity damage and injuries. Records relating to people’s skin integrity were not accurate and detailed to enable staff to support people safely. Three people who had skin damage remained in the same position for long periods of time. People were not always supported appropriately to manage risks, for example, 2 people did not have access to their walking frame despite being at high risk of falling. There was no evidence of people’s views being sought in relation to risk assessment and management.

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.

Oversight of environmental risks was ineffective. Parts of the environment were undergoing redecoration. Where redecoration was taking place in a lounge people were still able to access the area and no risk assessment had been completed in relation to this. An out of use shower room was accessible and people could at times access a staircase leading down from the first floor, due to the door not always being closed and secured properly.

Internal fire door checks documented concerns in relation to fire doors, yet limited action had been taken prior to the assessment. The management team on the first day of the assessment could not provide assurances the doors were safe, this was later addressed. However, some staff did not know how to operate external fire exit doors.

People had equipment available to them. However, this was not always correctly placed to support their safety. Since the last assessment the provider had taken steps to ensure people’s Personal Emergency Evacuation Plans (PEEPs) were up to date and the grab bag accessible.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Staff numbers and staff deployment at the service did not support safety and people did not always have their needs met. The service was operated across 3 floors and throughout the assessment staff were not always available to people on the ground and second floors. For example, 1 person on the second floor required assistance and there were no staff present until alerted by the inspector. In addition, some people were isolated in their rooms with task-based interaction only. One person remained in their bedroom from 06:55 until 16:30 with no meaningful interaction to support their wellbeing, and music continuously playing. The manager told us the dependency tool in place required review and was not accurate.

There continued to be no time allocated for staff, within their shift hours, to receive a handover.

Some supervision and appraisals had been completed. However, there were gaps in relation to this. There were also gaps in training, including dementia training, person centred care, MCA/DoLS, Fire Safety, and privacy and dignity training. In addition, 1 new staff member who should have been shadowing as part of their induction had completed a night shift included in staff numbers. The staff member had not completed their training, and their induction was not complete or signed off to demonstrate they were safe to support people as part of the staffing allocation. The manager told us they were not aware this had happened.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The service was clean and domestic staff were cleaning throughout. However, some people’s personal care had not been thoroughly attended to which posed an infection risk.

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

People’s medicines were available to be administered. However, for people prescribed ‘as and when required’ (PRN) medicines, there were not always in-depth protocols in place to ensure these would be given appropriately and safely. People that were prescribed creams did not always have accurate documentation to ensure staff would know how and where to apply these correctly, placing them at risk of harm.