Broom Cottage

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 the last inspection (publication date 2 March 2023) this key question was rated Good. At this inspection the service remains good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Lessons were learnt to continually identify and embed good practice.

The provider had systems and processes to learn from incidents and this was shared with staff. We identified from reviewing 2 ‘lessons learnt’ documents shared with staff following incidents, they did not fully reflect the incident report and actions required to mitigate risks, as recorded in the incident record. The management team advised this was an oversight and from speaking with staff, they were found to be knowledgeable about the actions required to keep people safe. However, this demonstrated a risk that documentation was not consistently reflective of current needs and procedures needed to be strengthened to reduce any possible miscommunication.

Management and staff meeting records confirmed incidents and lessons learnt had been discussed with staff. However, some staff told us they felt communication such as staff handovers and sharing of changes to people’s needs could be improved upon.

Relatives were positive about communication and told us they were kept informed of incidents and accidents and actions taken. A relative said, “If [relation] has a tumble, they [staff] let me know straight the way.”

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.

The provider had procedures of when and how information was shared with others. This included the sharing of information with others such as ambulance and hospital staff, in a document called ‘My Care Passport’. We found these documents provided others with important information to support consistency and continuity of care. However, from reviewing 1 person’s care plan records, we identified some important and essential information about health related procedures that were missing from their ‘My Care Passport’. Whilst this had not impacted the person the management team agreed to review and amend the information.

People living at the service had resided there a long time. However, the provider had transition systems and processes for any person transferring to the service. Such as a pre-assessment process, and opportunities to visit the service pre-admission dependent on the person’s needs and preferences. The provider also had a discharge process if a person was to transfer to an alternative placement, ensuring information was shared with others to support a smooth transition.

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.

Staff understood their roles and responsibilities in keeping people safe from abuse and avoidable harm. Staff completed ongoing refresher safeguarding training and had access to the provider’s safeguarding policy and procedure. Staff felt confident if safeguarding concerns were reported, the management team would act quickly.

Safeguarding procedures were in place and used effectively. Incident records showed incidents and accidents were minimal, and the local multi agency safeguarding procedures had been used when required, to report safeguarding to the local authority and the Care Quality Commission. Internal investigations and actions had also been taken to reduce further risks.

Staff told us and our observations confirmed, people living at the service got on well together. This was also confirmed by a person who told us people living at the service were all friends.

Systems and processes were in place to ensure restrictions placed upon people’s liberty were done so lawfully. The provider had a Deprivation of Liberty Safeguards (DoLS) policy and procedure and staff had received relevant training. DoLS authorisations were monitored for conditions and expiry dates and any new restrictions were reported to the local authority DoLS team.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plan and risk management guidance for staff lacked specific detail in places. People’s behavioural care plans provided staff with information about a person’s presentation of when they were having a good day and how they may present when experiencing emotional distress. Guidance included strategies to use to support and mitigate risks. However, we identified information lacked specific detail to support new staff who were less familiar with people’s care and support needs as this was a potential risk. We discussed this with the management team who agreed additional information was required and agreed to do this. From reviewing incident records we found there had been no impact on people.

The provider had risk management systems and processes. Risks associated to people’s individual care needs such as falls, epilepsy and choke risks had been assessed and planned for. Individual risk assessments provided staff with guidance of the actions required to mitigate known risks, these were reviewed monthly or sooner if required, our review of a sample of risk assessments confirmed this. Staff demonstrated an awareness of these risks.

Environmental and premises risks were assessed and planned for and regularly monitored and reviewed. This included risks associated with fire and legionella, a water bacterial that can cause serious illness. Staff had access to personal emergency evacuation plans, this was important information about how to support people safely in the event of an evacuation.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety audits and checks were completed on the environment and premises by staff at the service and by the provider’s estate teams. Records confirmed these monitoring systems and processes were effective.

Records confirmed actions planned to make improvements to the environment such as replacing flooring and upgrades from showers to wet rooms.

Relatives were positive about the environment and felt it was well maintained.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff recruitment procedures showed some shortfalls. For example, we identified a staff member did not have a recent photograph on their file and staff had not recorded the reason of leaving previous jobs and this had not been identified by the provider. We shared this with the management team who agreed to follow it up.

Management, leadership and oversight was a concern for staff. Staff raised concerns that there had not been regular management onsite, as the manager was responsible for another service. The management team agreed they were aware this had been an issue, and a new deputy and manager had been appointed, and whilst they would continue to manage a second service, they were now having regular attendance at the service.

People were supported by sufficient numbers of staff assessed as required. The staff rota confirmed staffing numbers had been consistent, and shortfalls had been covered by either bank staff (employed by the provider) or regular agency staff. However, the service had recently recruited permanent staff and there were no staff vacancies.

Staff received ongoing support. Staff told us and records confirmed, they received an induction and ongoing refresher training and opportunities to talk about their work, training and development needs.

People were observed to be relaxed within the company of staff. Smiles, laughter and appropriate acts of endearment were observed. Staff interactions with people indicated they knew and understood people’s individual needs well.

Relatives raised some concerns of the use of bank and agency staff and the concern they had of their relative being cared for by staff they were less familiar with. Positive comments were also received. A relative said, “We’re definitely happy with [relation] being there. They [staff] are good and look after them well.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The environment was found to be clean. Cleaning schedules confirmed cleaning tasks were being completed daily. Cleaning products were managed safely such as being locked away to protect people’s safety. Best practice was overall being followed and this reduced the risk of cross contamination. Staff were observed to be wearing personal protective equipment as required.

Staff had received Infection prevention and control training, and they had access to relevant policies. Audits and checks confirmed health and safety assessments and ongoing monitoring procedures were in place and working well.

Relatives told us they regularly visited the service and described the environment as good. A relative said, “It’s clean and tidy, [relations] bedroom has just had a new floor.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Electronic medication records had recently been introduced. The effectiveness of this was impacted by poor internet access. Whilst it had not impacted the safe administration of medicines, the poor access meant there was a potential risk. The management team were aware, and the provider had recently agreed to upgrade the internet, and this was planned to be installed shortly.

Staff had received training in medicines management, administration and had access to the provider’s policy and their competency had been assessed. However, some staff lacked confidence and awareness. STOMP - stopping over medication of people with a learning disability and autistic people is a national NHS England work programme to stop the inappropriate prescribing of psychotropic medicine medications, staff were not aware of this. However, the management team informed us they had already identified staff required further support and upskilling and had plans for this.

Medicine audits and checks were regularly completed and these confirmed where shortfalls had been identified, actions had been taken to make improvements. However, from reviewing records, we saw the room storage temperature was being taken, whilst staff were required to complete minimum and maximum temperatures this was not consistently being completed. This is important to ensure medicines were not being stored outside their recommended rangers, potentially compromising their quality and effectiveness. One person’s medicines were put in food due to swallowing difficulties, whilst records confirmed the GP had authorised this, it had not been checked with the pharmacist to consider if there were any risks of mixing this specific medicine with foods. The management team agreed to follow this up.

The procedures of ordering, receiving, and returning medicines followed best practice guidance. People had individual medicines care plans that provided staff with important information such as any allergies when and how to administer people’s medicines safely.

Feedback from an external healthcare professional said, “Medication is ordered in appropriate and timely manner for the residents, ensuring that they do not run out of medication.”