Archived: The Brookland

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 not being protected from the risk of abuse, risks not being managed well including the review and analysis of incidents. Although people received their medicines, there was a lack of understanding of what medicines were for and when they needed to be taken. Risks associated with people’s healthcare conditions were not understood or well managed: this left people at significant risk of harm. Infection, prevention and control practices were robust, and the environmental checks ensured people were safe. Staff underwent thorough recruitment checks.

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. Leaders and staff were not always recording incidents where appropriate to do so. The provider and staff told us about incidents involving people however, when we asked to see the reports relating to these, they were not provided. There was no analysis of incidents to look for themes and trends to reduce further occurrence.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. Leaders completed a hospital passport (a document that provides key information about a person, including their health needs, communication preferences, and any other relevant details that can help healthcare professionals provide better care). However, the hospital passport completed by the provider did not contain this important information. This meant that health care professionals may not have information to support the person appropriately and safely.

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. Whilst a family member felt their loved one was safe in the home, we found people were not protected from the risk of abuse. The provider told us that all incidents of unidentified bruising needed to be investigated by them and also reported to the local authority safeguarding team. However, we saw staff had completed a body map for a person where it was recorded the person had bruising on their ankles and thighs with a note stating the cause was unknown and that the person had not fallen. Despite this, leaders and staff had not investigated this or reported it the safeguarding team. This meant people were not protected from the risk of abuse.

There were inadequate processes in place to ensure risks were managed safely. Where people were at risk of falls and their mobility was impacted, there were no risk assessments completed in relation to this. Where people had seizures, there were no specific risk assessment in place and there was a lack of guidance for staff on how to support people when they had a seizure. The provider and staff gave differing accounts of what they would do in the event of a seizure. This meant that staff may not provide the most appropriate support. There had also been no risk management put in place in the event a person had a seizure at night when staff were asleep. There were also no choking or nutritional assessments or guidance in place for those people at risk of this.

The provider did not always detect and control potential risks in the care environment. The leaders did not always act in a prompt way to ensure that the environment was safe for people. One person required an adapted shower as their mobility had reduced. However, this was not actioned until a family member paid for this to be done. The family member told us they did this as the previous shower was a “Death trap.” This should have been the responsibility of the provider to address this. In 1 bathroom the wooden casing under the sink was degraded and the bottom of the radiator was rusted. In another bathroom the skirting was degraded. The bottoms of some of the cupboards in the kitchen appeared to have degraded from the heat of the kettle.

However, other areas of the home were well maintained. There were audits in place to check the safety of equipment and the building. Staff were recording the water temperatures when people had their personal care. There were checks in place to ensure staff understood how to evacuate safely in an emergency. Where maintenance issues occurred and reported by staff, these were addressed promptly.

The provider failed to ensure staff were effectively and safely deployed to keep people safe. Staff working hours were unsafe. The provider told us, and we confirmed from rotas, staff were doing 12 hours shifts with no breaks 3 days in a row and that member of staff was also the sleep-in member of staff each night of that shift. Staff also told us they were required to wake twice during the night to check on people. There were also no formal breaks provided to staff. This risked staff being fatigued and having no time to decompress. This placed people at risk.

The provider failed to ensure staff were suitably trained and supervised to carry out their role. Where people had epilepsy, acquired brain injury and mental health diagnosis, we saw from the training matrix that staff, including the leaders, had not been trained in these areas. This placed people at risk of not receiving safe care. Although supervisions were taking place, these were not effective as we identified shortfalls in practice in all areas of care being provided. None of these areas had been identified by the leaders or discussed during supervision and appraisals.

The provider operated effective and safe recruitment practices when employing new staff. This included requesting and receiving references and checks with the disclosure and barring service (DBS). DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns. The home was clean, tidy and well stocked with cleaning materials and personal, protective equipment. Staff completed cleaning check lists, and the leaders undertook audits to review the infection, prevention and controls.

The provider did not make sure that medicines and treatments were safe and met people’s needs. There was a list of medicines provided in the care plans but no detail on why these medicines were required for people. The provider was unable to confirm exactly why a particular medicine was required for 1 person and only that the person was on this medicine before they moved in. This meant leaders and staff may not act on any changes in the person’s health. Where people were on ‘as and when’ medicine, there was no medicine administration record (MAR) for this for staff to record should the person require this. We saw from 1 person’s MAR, they were given a medicine that according to NHS guidance, needed to be given with a main meal as this was more effective. However, we saw the medicine was regularly given in the morning before breakfast. The provider told us, and we saw from a person’s MAR, that 1 person’s sleeping tablet had been reduced to every other night. The GP had asked for the person’s sleep to be monitored on the nights they did not the medicine to see if this was having a detrimental impact on the person. However, staff told us they did not check on the person through the night. This meant, they could not be assured the change in the person’s medicine was effective.

Other areas of the management of medicines were undertaken in a safe way. MARs had a recent photograph of the person for ease of identification, details of the person’s GP and how they preferred to take their medicine. There were no gaps on MARs and staff accurately recorded the number of medicines that were left in the packaging.