Brandon Lodge Care Home

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 changed to requires improvement. 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Incidents, accidents, safeguarding concerns and complaints had not been regularly analysed to identify trends and ensure lessons were learnt. The regional manager confirmed the provider had systems to complete analyses, however the registered manager said they had not been made aware of this. The regional manager told us this would be addressed immediately. Staff confirmed they were encouraged to make suggestions and were listened to. A staff member said, “I am more than able to make suggestions to management or seniors or nurses on shift, and feel they are listened to, to a very high standard.”

The service 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. Various assessments had been completed on admission to identify people’s needs. However, more detailed information was required about people’s life histories to help staff gain a better understanding of the people they cared for.

The provider had systems to report and investigate safeguarding concerns. Previous safeguarding concerns had been investigated and action taken to help keep people safe. However, previous safeguarding concerns were not regularly analysed to identify lessons learnt. People and relatives confirmed they felt the home was safe. A person commented, “I am safe, I am not worried about anything.” Staff knew how to raise concerns if required and felt confident to do so. A staff member said, “I am confident if I needed to raise any issues. I have never had to do so in the past.”

Staff provided care to meet people’s needs that was safe and supportive. Risks to people’s safety had been assessed and plans developed to manage these risks. When people’s needs changed, staff assessed risks and updated plans to manage them. A staff member said, “We always discuss the problem and create a plan together to resolve the issue.”

The service did not always adequately assess and control potential risks in the care environment. The fire risk assessment lacked robust information about the severity and likelihood of a fire happening and the measures required to minimise the risk. The registered manager told us they had not been provided with guidance or training on how to conduct a fire risk assessment. Other health and safety checks had been completed as expected.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff were visible during our visits to the home and responded to people’s needs in a timely way. People and relatives confirmed staff responded in a timely way if they needed help. A person said, “Oh yes, there are plenty of staff.” Staff gave mixed views about staffing levels in the home. A staff member told us, “I feel there is enough staff and the rota levels are brilliant since I started, we do have enough staff to meet the needs of the residents.” Another staff member commented, “Sometimes we struggle but we just work as a team and manage the floor efficiently.”

The service assessed and managed the risk of infection. They promptly detected and controlled the risk of it spreading and shared concerns with appropriate agencies. The home was clean and tidy throughout, with domestic staff visible about the home undertaking their cleaning duties. Staff had completed Infection Prevention Control (IPC) training and gave positive feedback about IPC practices. A staff member told us, “Cleaning and standards in the building is spotless, same goes for the kitchen and laundry.”

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Medicines administration records (MAR) did not always assure us that oral medicines were being administered as prescribed. For example, we found that remaining stocks of medicines did not always reconcile with signed for administrations.

The service had no processes in place to record the administration of thickener (a medicine used to thicken fluids to aid swallowing). The service implemented a process post inspection, but we could not assess the full effect of this until embedded in practice.

Topical medicines application was not robust, and we were not assured that contemporaneous records were being completed as staff signatures were not who had physically applied the topical medicines. We also found guidance was not always in place to support staff on where to apply topicals.

When required medicine guidance was in place however the service was not always following their own policy in relation to the recording of when required medicines. For example, the service did not always record the time, why medicines were administered and any follow up of effectiveness.

Handwritten entries of MAR charts were common in the service, however we found that warning labels were not always transcribed, and entries were not double signed for accuracy.

Care plans were in place however further detail was required for some service users with more complex conditions.

Audits in the service were taking place however they had not identified all the concerns found during the assessment.