Brook View

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 requires improvement. At this assessment the rating has remained unchanged. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

At our last inspection the provider was in breach of regulation in relation to medicines management. We saw during this inspection this had improved, and they were no longer in breach of this regulation.

This service scored 62 (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. There was a positive learning culture. Staff were encouraged to report incidents and near misses, and lessons learned were shared through meetings and feedback folders. A “no blame” approach was promoted, and staff felt confident to raise concerns. Documentation showed that incidents were investigated and used to improve practice.

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. People’s transition into the service was well supported. Initial assessments and hospital passports were used to plan care prior to admission. Feedback from professionals indicated that care planning had improved under the new manager, with more personalised and detailed documentation.

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. People told us they felt safe, and staff were trained in safeguarding procedures. Deprivation of Liberty Safeguards (DoLS) applications were appropriately submitted, and safeguarding concerns were escalated to the local authority when needed.

The provider did not always work well with people to understand and manage risks. Whilst staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, some risk assessments required further detail and associated information lacked some detail. For example, 2 people were identified as high risk for gum infections, but oral care was not consistently recorded, despite it being delivered. When it was recorded and people had refused, further details were not included in the risk assessment to instruct staff. Also, on day 1 of our inspection, some areas of these plans, such as 1 person’s choking risk assessment, lacked detail, this placed people at risk of not receiving care in line with their needs. The provider responded promptly to our feedback and amended these care plans to include more detailed information to guide staff and help ensure safe care.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was clean and well maintained. Health and safety checks were in place, including fire safety, Portable Appliance Testing (PAT) and legionella assessments. People were involved in shaping the support through ambassador roles and direct reporting to the executive team at exemplar. For example, we saw how 1 service user ambassador had made comments and changes around outings and trips for people at the home.

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. Staffing levels exceeded dependency needs, and rotas were managed electronically. Staff were safely recruited and received mandatory training, including Positive Behaviour Support, and mental health awareness. Staff wellbeing was monitored, and morale had improved under the new manager.

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. Monthly Infection Prevention Control (IPC) audits were conducted, and Personal Protective Equipment (PPE) was readily available. Information boards and business continuity plans were in place. Staff were observed wearing correct PPE.

The provider now mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were now administered safely and in line with protocols. Electronic Medication Administration Records (EMAR) systems included photos and expiry dates, and ‘as required’ medicines had protocols in place. Medication compliance improved from 72% to 94% this meant people were more consistently receiving their medicines as prescribed. However, some inconsistencies remained with record keeping in relation to medicines. For example, where people required their drinks to have fluid thickener added for their safety and the recording of the application of prescribed topical creams.