Brailsford 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

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

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation. This is because people were not always supported to be safe from harm, or remain safe from abuse.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a positive learning culture. Staff had written down how 1 person had harmed another person living at the service. This had happened over 2 months ago, but staff had not received updated care plan guidance on how to reduce the risk of this harm in future. However, we saw other incidents were recorded by staff, and action was taken to ensure improvements were made.

The service worked with people and healthcare partners to establish and maintain safe systems of care. This meant people were referred to external healthcare partners when needed. They were also supported to have safe transitions back to the care home after a hospital admission.

People were not always safe from abuse. While people told us they felt safe from abuse, records showed that safeguarding referrals had not always been made as expected. Records showed that 3 people had been physically harmed by other people living at the care home. This is considered physical abuse against a person made vulnerable by their care and support needs. The registered manager confirmed that these incidents had not been referred to the local authority safeguarding team as expected. The manager agreed to send these referrals after our inspection. However, 2 of these incidents had happened over 6 months ago and therefore referrals had not been made in a timely way.

The service did not always ensure risks were managed safely. This was because care plans did not always provide enough information on how to support people’s physical and mental health needs. For example, one person had a physical health diagnosis. Staff did not have guidance on how to monitor the person’s symptoms or guidance on when to take further action if their health deteriorated. People told us that they had not always been involved in planning for their health care conditions.

The service did not detect and control potential risks in the care environment. The stairs were not safe as there was no second handrail which is contrary to best practice health and safety guidance. Radiators were not covered, which posed a burns risk if the radiator was touched by people living in the care home. These 2 risks had not been identified in the provider’s refurbishment plan. We spoke with 7 staff who told us they were concerned about the state of the environment and felt their concerns had not been acted on.

The service did not always make sure there were enough staff. We saw 1 incident where a person needed to wait for staff support. While waiting for support to go to the toilet, they attempted to stand unsafely. Staff attended quickly when this was raised by the inspector. Other than this incident, we saw staff were usually available to support people quickly. We were told by 7 staff they felt there were not always enough staff at the service. These staff told us that staffing levels impacted helping people: go to the toilet, receive effective personal care, reduce their agitation or engage in activities. The provider told us that they had previously increased staffing levels when staff had fed-back concerns. Staff told us they received good quality training. We saw that the majority of training was up to date for staff.

Some areas of the home needed refurbishment, and this impacted the cleanliness of the care home. For example, following a water leak, areas of carpet needed replacement which made it hard to effectively clean these areas. During the inspection we saw the provider taking action to improve the refurbishment of the building following this water leak. Some staff told us they felt further improvements were required to the maintenance of the building. One staff member told us “The home looks dirty, and I am embarrassed about the state of it at the moment.”

The service did not always ensure the safe administration of ‘as needed’ medicines. Staff had regularly given ‘as needed’ medicines, but not reviewed whether this was effective with the prescriber to determine if a more routine prescription was needed. Staff did not always record clear reasons for giving ‘as needed’ medicines or review the effectiveness of the medicine. For example, staff wrote paracetamol was given for ‘pain’ but did not record the location or severity of this pain. There was no recorded evidence that staff later reviewed the effectiveness of this pain relief with the person. Other than ‘as needed’ medicines, we found medicines were stored appropriately and managed safely.