Brook House

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

We identified 1 breach of the legal regulations. The provider had not managed risks to people’s safety effectively or learnt from previous safety concerns. Environmental and infection prevention and control concerns were not always well managed. People's medicines were not always managed safely. Staff were not always visible and available to meet people’s care needs. However, we found staff knew how to recognise and raise safeguarding concerns and the provider had appropriate processes in place for notifying the relevant authorities and addressing safeguarding concerns.

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.

People and relatives told us they felt confident raising safety concerns with the provider. However, we found the provider had not always learnt from previous health and safety concerns to ensure people experienced consistently safe care. For example, some concerns with the provider’s fire safety and infection prevention and control processes identified at the last inspection remained at this assessment. This placed people at continued risk of harm.

Staff knew where to record incidents and accidents and told us lessons learnt were discussed during 1:1 supervisions and team meetings. The management team showed us examples of how their investigation reports had addressed incidents and identified learning for the team.

The provider's processes for addressing and learning from safety concerns were not always effective. Whilst we found some evidence of lessons learnt, not all health and safety concerns had been addressed since the last inspection. This meant measures had not always been put in place to mitigate risks and improve people’s care.

People had information about their health and support needs in their care plans which could be shared with relevant health professionals when required to promote continuity in people's care.

The provider told us they documented people’s healthcare needs and shared relevant information with other healthcare professionals when making referrals and accessing other healthcare services. Staff were aware of the importance of sharing information when supporting people with health appointments and during hospital admissions and discharges.

Health professionals confirmed staff and managers were knowledgeable about people’s needs but we received some mixed feedback about how well concerns were prioritised and raised with other health services to ensure risks were managed safely.

The provider’s processes had not always ensured there was effective collaboration with other health professionals. Health professionals did not always feel risks were identified and managed proactively to ensure people remained safe.

People told us they felt safe and knew how to raise any concerns. The provider had ensured information about how to raise safeguarding concerns was available to people and relatives.

Staff understood how to recognise and report safeguarding concerns. Staff had access to safeguarding and whistleblowing policies and procedures and told us they had received safeguarding training. The management team told us they discussed safeguarding at each team meeting to support staff knowledge and understanding.

We observed people receiving safe care from staff during our assessment, with no safeguarding concerns identified.

The provider had processes in place to protect people from the risk of abuse. Safeguarding notifications had been raised appropriately and incidents were investigated with actions identified.

Risks to people's safety were not well managed. For example, we found people did not always have up to date and accurate fire evacuation information in place. This meant staff may not know how to support them to evacuate safely and the emergency services attending may not have the correct information about who was in the building and where they were. This placed people at risk of harm. Not all relevant risk assessments were in place to provide staff with guidance about people’s health conditions and related support needs. This meant staff may not understand how to support them safely.

Whilst we found staff did not always have appropriate guidance in place to manage risks to people safety, staff we spoke with were able to identify people's individual risks and explain their support needs. The management team told us they did have processes in place to review fire safety and risk assessment documentation but acknowledged information had not been updated as promptly as required when people had been admitted into the service or where people were no longer living there.

During the first day of our assessment site visit, we found items of furniture and wheelchairs stored under the stairs which were impacting on people’s safe access to the fire exit. This posed a fire safety risk. The management team responded promptly to our feedback, repositioning items to ensure unhindered access.

The provider's processes for reviewing and managing risks were not robust. The provider’s health and safety checks had not identified fire safety and risk assessment documentation which was not in place or up to date.

The environment people lived in was not always well maintained. We found some fixtures and fittings in communal and ensuite bathrooms were very worn and in need of repair or replacement.

Staff told us they were provided with training in the use of people’s equipment. The management team showed us the health and safety checks they completed to monitor the safety of the premises and equipment.

We observed items stored on top of people’s wardrobes which could pose a risk if they fell. The registered manager told us all wardrobes were attached to the wall to prevent the risk of falling; however, no checks were completed to evidence how this was monitored.

The provider’s processes for managing the safety of the environment were not always robust. Whilst the provider regularly completed equipment and environmental audits of the service, we identified concerns during the assessment which had not been addressed.

Staff were not always visible and available to provide people with personalised care which met their needs and preferences. People and their relatives told us staff did not always answer call bells promptly and this meant people had to wait for continence support and personal care

We received mixed feedback from staff about whether there were enough staff on shift to ensure people received prompt care and support. The management team told us they had not always completed regular audits of people’s call ball data to check how long they were waiting; however, this was something they had now implemented and they would continue to review staffing availability throughout the day. Staff told us they had completed appropriate training relevant to their role and received regular supervisions

We observed people who required continence support looking for staff and not being able to find them. We also observed one person who was feeling unsteady on their feet trying to find a member of staff to provide support. We gave this feedback to the management team who told us they would review staffing deployment across the building.

The provider's processes for recruiting staff were not always robust. Employment checks had not always been completed in line with the provider’s own recruitment policy. For example, employment references were not requested for applicant's previous care positions. The provider has a system in place to calculate what staffing levels were required to meet people’s dependency needs. However, we were not assured these processes were robust as the feedback we received and our on-site observations evidenced staff were not always available when needed. The management team had processes in place to monitor staff training and they completed regular competency checks to ensure staff understood their training.

People were not always protected from the risk of infection. Communal bathrooms were not always cleaned to a high standard and we found hair and dust, stained flooring and a build-up of limescale. People’s personal items were not always stored appropriately. For example we found hairbrushes and razors in communal bathroom cabinets. This presented an infection control risk.

Staff had received infection prevention and control training and were able to tell us what good infection prevention looked like. However, we also found not all staff were adhering to the provider’s own infection prevention policy in relation to hand hygiene, jewellery and artificial nails. Following the assessment, the provider confirmed they had completed refresher discussions with all staff.

We found heavily corroded and stained toilet pans in people’s en-suite bathrooms. This meant effective infection prevention and control processes could not be maintained as the surfaces were not intact and in good condition. We also found used personal protective equipment [PPE] in open dustbins. Following our feedback the provider responded promptly to replace the damaged toilets and allocate additional cleaning hours to monitor bathroom cleanliness.

At our last inspection, we identified concerns with the provider’s laundry processes. At this assessment, we found significant improvements had been made in this area with new laundry equipment purchased and a clear process in pace to ensure safe laundry hygiene. However, we found there were still infection control risks present in other areas of the building. The provider told us they completed regular infection prevention and control audits and evidenced where they had identified the concerns with the poor condition of some toilets. However, whilst this concern had been identified, no action had been taken prior to the assessment to replace the heavily corroded items.

People’s medicines records were not always completed accurately. This meant there was a risk people may not receive their medicines as prescribed. For example, where 1 person required support to apply a transdermal patch [a patch attached to the skin containing medicines], the application chart had not always been completed correctly to show where this had been applied. Where people were prescribed medicines to support them during episodes of distress, we found staff were not always accurately recording when and why these medicines had been administered. This place people at risk of receiving their medicines inappropriately.

Staff who administered medicines had received training and told us they had their competency checked. Following the assessment, the management team confirmed they had completed a team meeting with all staff who administered medicines to discuss our findings and would be putting additional monitoring in place to ensure improvements were made.

The provider did not always have effective processes in place to ensure people’s medicines were managed safely. We found a number of concerns with the recording of people’s medicines including inaccurate or incomplete entries and handwritten entries which were not legible. These concerns had not been addressed by the provider’s own auditing processes. We also found the temperature of the medicines was consistently being documented as too warm; however no action had been taken to address this prior to our assessment. Following the assessment, the provider confirmed they had received quotes for air conditioning units and were also considering relocating the medicines room to ensure better temperature control.