Brockworth House Care Centre

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

People told us they felt safe; however, relatives were not always assured of the safety of their loved ones. Staff told us care was delivered safely. We received some feedback however not all working practices were always delivered in line with best practice guidelines. We observed people were cared for safely, but not always in a person-centred way. The documentation we reviewed recorded the actions taken and the processes which were followed to support people safely. Measures were in place for the manager to have oversight of these to ensure people remained safe. The evidence we collected did not always reflect the feedback we received from relatives.

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.

We received mixed feedback from people and their relatives. People told us they liked the staff, and the staff knew their needs. Some relatives told us they did not always feel listened to when they raised concerns about people’s safety.

The provider had oversight of accidents and incidents and worked with professionals when people’s needs changed. For example, a person experiencing a high number of falls was assessed and changes were made to this person’s care to help protect them from further harm by introducing 1:1 support. Staff told us they would be confident any concerns raised to the provider would be acted upon.

Systems and processes were in place to support continued learning. Incidents and safeguarding concerns were recorded and investigated. Learning was shared via training and supervisions with staff to reduce the likelihood of incidents occurring again. The manager fostered a culture supportive of learning, and there were plans to implement a weekly ‘Teach me Tuesday’ session with staff to encourage development and increase knowledge.

We received mixed feedback from people and their relatives. Some people told us they felt listened to, while others did not. For example, one person told us “Staff are always around, and I don’t have to wait more than 5 minutes when I press my call bell.” Relatives told us they felt the nurses and manager did not always escalate their concerns in a timely way to partner agencies.

The provider worked with the local authority to meet people’s physical and emotional needs. This included providing one to one support to keep people safe. Staff told us their views were listened to and acted upon. A staff member told us how they supported external professionals who visited the care service, they said “When the last Speech and Language Therapist (SALT) came, I asked the kitchen to present the different levels of food in different bowls and this worked well.” This meant the therapist could observe people viewing and interacting with the food and this led to a more positive experience for both the therapist and the person.

We reviewed evidence from visiting professionals who were complimentary of staff practice and the care being provided. We received positive feedback from professionals who shared staff at the service communicated well with them.

We received mixed feedback from people and their relatives. Relatives told us they were not always satisfied with outcomes of investigations into allegations and concerns of abuse. For example, one relative felt they were not kept informed of the progress of an internal investigation into their complaint regarding a staff member. Relatives told us they were sometimes concerned for the safety of their loved ones. For example, one relative told us they believed staff were not attending to their relative’s continence needs in line with their plan of care. People told us they were supported to understand safeguarding, what being safe meant to them, and how to raise concerns when they didn’t feel safe, or if they had concerns about the safety of other people. People told us they did not feel unsafe or neglected. For example, people told us they knew they had to wait for staff to help them if they were unsteady on their feet.

Staff had received training in safeguarding and understood the signs which could mean a person was at risk of harm and/or abuse. Staff told us they would report concerns to the provider, and they were confident any concerns would be actioned.

We observed staff deliver care safely and we observed staff using appropriate manual handling techniques. We observed people to be comfortable in the company of staff. Staff were observed to respond to people’s requests and provide them with the support they asked for.

The provider had a system for the management of safeguarding concerns. This meant people were protected from the risk of harm or abuse. Staff had received training to recognise abuse and knew what action to take to keep people safe, including reporting any allegations to the appropriate person or authority. The provider had processes in place for learning and making improvements when things went wrong. Staff recorded accidents and incidents, which management reviewed on a regular basis to identify any trends, themes and areas for improvement.

We received mixed feedback from people and their relatives. People told us they were not restricted. People told us they could go wherever they wanted and could ask staff if they wanted to go outside. Relatives were concerned staff did not always know people’s needs and they received a poor response from the manager when they requested reviews. For example, one relative told us they were concerned the manager did not conduct appropriate reviews for bed rails when requested.

Staff told us they felt people were supported to manage risks. Staff told us they did not receive specific training on medical conditions, and they felt they could benefit from this. The manager was addressing this shortfall in training by introducing a new initiative called ‘Teach me Tuesday’. The manager told us staff are encouraged to put forth ideas for training they felt would benefit them. The service also had an in-house trainer. Staff told us they were aware of people’s risks and were aware of how to support people in the least restrictive way.

We observed there were staff visible in the corridors and around the service. We observed call bells were answered in a timely manner to ensure people were safe. We observed staff in the dining room during lunch assisting people with their meals. Staff appeared confident and to know people well. People were encouraged to independently access communal areas and gardens, while staff observed them from a safe distance.

We saw the manager had systems and processes in place to assist in safely managing risk. We saw evidence the manager had applied for Deprivation of Liberty Safeguards (DoLS) appropriately, however we found one person’s authorisation had expired by 1 month. There was no direct impact on the individual and the manager assured us they would review their system for monitoring when DoLS authorisations expired. We saw appropriate steps were taken when a partner agency noted staff were using restrictive practices, which were not in line with the providers policy. Care documentation contained accurate information on which risks people had and had appropriate information for staff on how to support people safely.

We received mixed feedback from people and their relatives. People told us they felt safe and were happy. Relatives told us the environment was not dementia friendly and they had concerns with the safety of the environment. One relative was concerned about equipment not being checked regularly and this resulted in a near miss when their relative’s feet came off a wheelchair’s broken footrest. One relative told us the carpet in their relative’s bedroom needed to be replaced, but over the course of several months, no action had been taken.

Staff told us equipment was checked and cleaned by the night staff, and any issues were reported to the maintenance team and through the shift handovers. Staff were able to explain how to check if a sling was safe to use. The manager told us they undertook daily walk-arounds to identify any issues and there was a full-time maintenance person and housekeepers.

We observed the interior of the service to be clean and tidy. We observed some dementia friendly activities which had produced decorative bowls, these had been made by people who lived in the care service from vinyl records. This had been part of week long music themed activity. The manager showed us new furniture which was going to be used as part of a refurbishment project to make the lounges more dementia friendly. The manager explained a refurbishment project was starting which included updating the carpets and painting the walls. We observed some dementia friendly décor in the downstairs lounge/dining room of items hanging from the ceiling as well as different coloured toilet seats. The hallways did not have dementia friendly décor, they were mostly bare and had minimal visual items or interactive displays. There were areas which needed improvements such as the carpets and paint. We observed some concerns with the outside areas which we brought to the manager’s attention. Some people’s bedrooms looked out onto the refuse bins which may not be pleasant for people. There was a broken lock on the fencing to the refuse bins which we observed information about being handed over to the maintenance person. We were also concerned with the prefabricated trailers outside where the housekeeper’s office and staff rooms were. We addressed with the manager a lack of outdoor lighting and fire safety measures. The manager assured us they would address these concerns. There was also a wooden shelter where staff could smoke and there were noticeable holes in the siding. The manager explained she was in the process of getting the building removed, which would mitigate the risks. People had limited access to these buildings, however as they were located close to the main building, if a fire were to break out, it may be possible fire could spread to the main building.

We saw there were appropriate systems and processes in place to identify concerns with the environment. We saw checks had been done regarding fire safety, Legionnaires disease and equipment checks were in line with health and safety legislation. We observed areas which had been identified as needing to be replaced or repaired were being addressed. We saw the manager had completed regular fire drills and people’s fire safety documentation was in place, to assist staff in the event of an evacuation. On the days before the inspection, we were made aware of a power cut which had affected the entire service, and on the day of the inspection we saw evidence of repairs being made by the power company to restore power to the building. We saw evidence of the emergency plans which had been implemented during the power outage and where staff had acted in line with the provider’s health and safety policies. While systems were in place they were not always effective in identifying issues found during the inspection with safety of the environment.

People and their relatives told us they felt there were not enough staff. People told us they would like to see more staff, but they didn’t have to wait too long for their call bells to be answered. Relatives stated they felt there were not enough staff on the second floor and on the night shifts. Relatives were also concerned with the amount of agency staff the care service had been using.

Staff told us there were generally sufficient numbers to ensure people’s care needs were met. The manager told us the service was sufficiently staffed based upon a dependency tool which was in use. Staff told us they would like more training, especially more dementia training.

There appeared to be enough staff. We observed staff to be visible and available to meet the care needs of people living at the service. People who required 1:1 support from staff received this, and we observed call bells to be answered in a timely manner. Staff did not appear to be rushed, and we observed positive interactions between people and staff.

We reviewed the dependency tool used by the provider and saw the tool advocates for less staff than were rostered. The manager explained they felt the need to increase staffing levels beyond what was advised by the dependency tool, and the area manager supported this. We reviewed 3 staff recruitment files. We reviewed evidence which included staff training, supervision and appraisal records, and saw evidence of future training booked with the in-house trainer.

People were supported to take their medicines correctly and at the right time. This was recorded on their medicines administration record (MAR). Individual needs and preferences were considered when administering people’s medicines.

Staff told us what systems and processes were in place to monitor people’s health and they knew the signs which indicated someone was unwell. Staff told us how they would escalate concerns, and they were aware of how to report someone’s deterioration to different health partners, such as the GP and 111. Feedback from health professionals was there was some inconsistency in when they were called out, and they told us staff who contacted them may not have all the necessary information needed.

We observed staff wearing appropriate personal protective equipment (PPE), such as gloves and aprons. We observed staff washing their hands and using hand sanitiser. We observed correct infection control practice when staff assisted people to eat in the dining room. We observed there were enough hand washing stations and stocks of gloves and aprons. We observed there were now posters in place showing how to correctly put on and take off PPE, which had been a part of the previous breach of Regulation 12, Safe Care and Treatment.

We saw the manager had appropriate audits in place to monitor infections and the last recorded outbreak of an infection was December 2023. We saw records kept by the cleaning staff which recorded when deep cleans of people’s rooms had been conducted after they had been unwell. We reviewed the provider’s infection control policy and infection control audits, which were done quarterly.

People were supported to take their medicines correctly and at the right time. This was recorded on their medicines administration record (MAR). Individual needs and preferences were considered when administering people’s medicines.

Staff were proud of the work which had been done to improve the management of people’s medicines in the service. Staff told us they received annual medicines training and competency checks. Staff worked closely with the GP and other healthcare professionals to resolve issues with medicines in a timely manner.

There were processes in place to ensure people received medicines safely and in line with best practice and manufacturers’ recommendations. Medicine records were accurately completed. Medicine audits were undertaken and there was a system in place for reporting medicine related errors. Lessons learnt through these processes were being used to drive improvements in the service. Staff were aware of national guidance on managing dementia symptoms with medicines and processes were in place in the service to ensure psychotropic medicines were regularly reviewed. Care plans contained information to support staff with the safe administration of medicines. However, in some cases this lacked adequate person-centred detail. For example, the risks associated with anticoagulant (blood thinning) medicines, which can cause bleeding and bruising, was not always detailed in people’s care plans. There were arrangements in place for safe storage and disposal of medicines. However, prescribed creams were kept in residents’ bathrooms rather than in locked cupboards. No risk assessment was in place for this practice.