Brendon 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 – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained 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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always share concerns appropriately. Policies, systems and processes around safeguarding were not always consistently or effectively carried out and completed. We identified 1 breach of legal regulation in relation to failure to notify CQC of all safeguarding incidents. For example, although leaders reviewed incidents and took action to keep people safe from abuse and had alerted the local authority, leaders had not always submitted safeguarding notifications to CQC, for them to assess if any further actions were required. People were observed to be well cared for and treated kindly by staff and clearly felt safe with them. Staff understood their role when protecting people against harm and how to report any concerns about abuse. One staff member said, “I would raise any concerns with my manager, I could also go to head office or go to CQC or whistle blow.” Staff had completed the relevant training in safeguarding. The registered manager had a clear understanding of their responsibilities in relation to the Deprivation of Liberty Safeguards (DoLS).

The service worked with others 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. Staff had an understanding of people’s risks. Staff said that risk assessments were completed by the management team with involvement from staff, families and other health professionals. People had specialist equipment to support their needs, for example wheelchairs, walking aids, bed rails and electronic profile beds. Safety certificates were in place for both the lift within the service and the tailgate lift for people to safely access the minibus. Plans and risk assessments were detailed, individual risks were identified in people’s plans identifying steps for staff to follow to help keep people safe. The registered manager had already identified where improvements could be made in involving people more to develop their own care plans and risk assessments. However, this work had not yet been commenced to ensure people could actively participate fully in these processes. Information was included in people’s records where they had input from other professionals. There were processes in place for monitoring fluid, dietary and health needs.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service had processes in place to ensure that all staff are suitably experienced, competent and able to carry out their role, however these were not always followed. For example, we were not always assured that staff were receiving their supervisions or annual appraisals in line with policy. The registered manager told us that they have devised a supervision monitoring schedule to ensure that all staff received appropriate support and supervision. Some staff we spoke to said that they had not had a recent supervision or appraisal, however they did feel that they could speak to the manager if they needed to. The provider had an internal recruitment team, who helped to ensure staff were compliant with requirements of schedule 3 of the Health and Social Care Act 2008. There were processes in place whereby a manager from another service would carry out spot checks for night workers. There were enough staff on site throughout our visit and the rota’s reflected the hours of support the service was being funded to provide. We were not always assured that all staff had completed training relevant to their role. The provider’s training records reflected gaps where some staff had not completed training in key areas, such as PEG training and dysphagia however we were assured that at least one trained member of staff was present at each shift. Staff said that there were opportunities for further development within the organisation.

The service assessed and managed the risk of infection. The service had processes in place to assess and manage infection control. We found that the provider did not always review their policies in line with the timescales they had set out. For example, the infection control policy had not been reviewed since August 2022. We discussed this with the registered manager who took immediate action to address this. Staff completed infection, prevention, and control training and understood how to minimise the risk of infection control. Staff confirmed that there were sufficient supplies of personal protective equipment (PPE) available.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff said that they received assistance in supporting people using the service, from visiting healthcare professionals such as pharmacists and specialist nurses. This included evidence of regular medicines reviews. The service had safe systems and processes in place to safely administer, record and store medicines, however these were not always followed. For example, incidents were not always recorded and investigated in line with the providers policy and medicines audits were not always effective in identifying issues. Staff had received staff training in the safe management of medicines and were assessed as competent; however staff training records were not kept up to date. Medicines were stored securely, but we were not assured that they were stored in line with the manufacturers recommended temperature range. Care planning was in place, this was detailed and centred around the person’s needs, although this did not include how people would like to be, or how they may be able to be involved with their medicines. Information was not always consistently recorded across all care and administration records. We were unable to observe the administration of medicines, although we saw no evidence of inappropriate use of medicines, including medicines to manage behaviour on the day of inspection.