Bryony Lodge

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 – 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 breach of legal regulations related to safe care and treatment due to concerns in management of safe environments, infection, prevention and control and medicines management.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements had been made following our previous inspection. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff knew what incidents to report and how to report them. The manager shared learning with staff through team meetings and supervision sessions.

The service 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. The provider had an admissions policy, and the manager was able to explain the process. They told us, “We would read the person’s previous support plans. We would undertake an assessment. We would look at the environment to see if it was suitable for their needs and assess their compatibility with the other people who live in the home. We would assess the persons mobility and health needs to see if we need professionals to come in and provide additional support.”

Improvements had been made following our previous inspection. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. The service shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies. They also had a safeguarding tracker in place to monitor progress.

Improvements had been made following our previous inspection. The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. For example, people were assessed for risks of falls, risk of choking and risks when using the kitchen. When risk had been identified staff followed actions to keep people safe such as providing additional equipment and the appropriate level of support when a person was in the kitchen. The manager told us, “It is about getting people involved in the day to day tasks. Explaining risks involved, assessing, making sure they understand the risk and writing risk assessments which are person centred and then reviewing them.”

The service continued to not always control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Fire safety checks were carried out on fire doors in the service, but defects were not always identified, and prompt action was not taken when defects were identified. These concerns meant in the event of a fire, people were at significant risk. We reported our concerns to Hampshire fire service. The provider took remedial action following our visit and organised for a contractor to undertake works to the fire doors. We asked to review the fire grab bag within in the home, the provider told us there was not a grab bag in place. This meant in the event of a fire evacuation at night, there was no torch, high visibility jackets or blankets available. The fire blanket in the kitchen needed replacing because the ‘how to use’ instructions had faded. This meant in the event of a fire, the staff may not know how to use this equipment safely. We reviewed documents of fire evacuations staff had undertaken which evidenced not all staff had participated in a fire evacuation drill in the last 6 months. The manager told us, they would ensure these staff participated in a fire evacuation. The provider ensured routine testing had been carried out, for example moving and handling equipment, gas, and electrical testing.

Improvements had been made to staffing numbers following our previous inspection. Relatives and staff told us they thought there were enough staff. We reviewed people’s activities and observed people did not always have the opportunity to participate in external activities on a regular basis. We spoke to the provider about this who told us they had sought additional funding for some people and with a new manager in post, they were confident external activities would improve for people. Time was needed for these planned improvements to be completed. We reviewed training records and noted some staff had not completed all their required training, the provider was proactive and organised for staff to complete the training. Some staff recruitment records were incomplete. The provider told us what action they were taking to strengthen their recruitment systems.

The service continued not to always manage the risk of infection. During our first on-site inspection visit, we observed concerns with waste management. The kitchen was tired with cupboard doors and plinths which were chipped. These concerns presented an infection risk as could not be cleaned appropriately. In the kitchen, we found food was not always managed in accordance with good practice increasing the risk of contamination. We spoke to the provider about our concerns, and they started addressing these during the inspection. The provider told us, they were aware of the concerns in the kitchen and the replacement of the kitchen was on their schedule of works programme.

We found ongoing concerns in relation to people’s medicine management. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. During our first on-site inspection visit we observed, some medicines which were in medicine cupboards were not on people’s medication administration record (MAR). We were concerned the disposal of medicines policy had not been followed. The risk assessment for flammable creams was not robust. It did not detail the temperature to wash clothes at daily to avoid build up and keeping people away from possible ignition. This meant people were at risk of burns if they got close to a source of ignition. We reviewed PRN protocols for the people living in the home. We found the protocols were not always clear about the dose to be administered. This meant people were at risk of being administered the incorrect dose of medicine. We spoke to the provider about our concerns, and they started addressing these during the inspection. We observed staff safely administering medicines to people.