Brandon 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

During our assessment of this key question, we found the provider was failing to meet their legal requirements and were in breach of regulation 12. We found concerns around the safe delivery of care, the management of risk and medicines management. You can find more details of our concerns in the evidence category findings below. The systems in place to report and learn from accidents and incidents required improvements to ensure they were effective and to safeguard people from avoidable harm. However, people told us that they felt able to speak about their concerns. We received mixed feedback from people about feeling safe in the home. Not all of the management team were clear on their responsibilities and duties to identify and report safeguarding concerns. Not all safeguarding incidents had been reported to CQC as required. There was no evidence that safeguarding incidents had been audited or any evidence of lessons learnt. Most people we spoke with told us there were not enough staff to meet their needs and that agency staff were often used. Systems were not effective in ensuring staff were recruited safely. People told us they felt the home was clean and well maintained. However, we found some areas of the home required re decoration and further maintenance. We saw staff followed safe practices to prevent and control the spread of infection.

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.

People told us they could speak to staff and management if they had concerns around safety and they would be listened to. One person told us “I made a complaint, a member of staff put my tablets in my mouth, I reported it because it was dangerous to it put in my mouth. They usually give them to me to take. I reported it to a staff member, and she acted. It was reported to the authorities and the council rang me. It was agency staff, and they haven’t been back. I was satisfied with how they dealt with it.”

Staff told us they did not feel the culture was positive. Staff said they would not be able to raise concerns or report poor practice to the manager at the moment. Some comments included, “The last manager had an open door policy which made us feel comfortable to enter into the office and discuss any matters at hand but now a simple good morning even goes a miss and when issues are raised it seems to be brushed under the carpet unless it is of a very serious matter” and “I feel when I go (to see the manager) I’m looked down on.” The regional manager told us the home was in the process of getting a new quality and compliance system to improve oversight and governance for the service.

We found no evidence incidents were reported or investigated thoroughly. For example, one service user was observed to have bruising which had not been reported or investigated. The provider had not ensured that the systems in place to make sure managers and staff learned from events such as accidents and incidents, concerns, and investigations were effective.

People told us they had a pre admission assessment prior to them moving into the home and felt safe during their transition.

Management told us there was systems and processes in place for people moving into the home with pre assessments carried out to ensure a safe transition. However, we found some people’s transitions were not always managed safely. or example, one person was admitted to the home on 28 May 2024 and did not have all care plans or risk assessments completed during our visit on the 11 June 2024. This meant that staff did not have the information to be able to meet the person's needs safely and consistently.

On gathering feedback from the local authority commissioning and safeguarding team, no concerns were identified in this area.

Processes and systems for people moving into the home were not always effective. For example, care plans and risk assessments not being completed in a timely manner and staff not following preadmission information given to them. During our assessment we carried out lunch time observations and found one person asking for chips with their lunch. The staff member told them they had to have mash potato due to a soft diet. The staff member was unsure of how to support the person with their food and fluid intake due to no risk assessment or care plan in place. We checked the preadmission documents which stated the person required a normal diet. This meant the person was not given a choice of meal as a result of poor record keeping and a robust transition into the home.

We received mixed feedback from people in relation to people feeling safe. Comments included, “I do feel safe here, it’s lovely, it’s a very good place. Some days I am happy here and other days I am not, it depends how I am feeling” and, “I am safe here, I haven’t had any problems with anyone. I get along with everyone here” and, “I suppose so, sometimes people are off hand with me.”

Not all of the management team were clear on their responsibilities and duties to identify and report safeguarding concerns. Not all safeguarding incidents had been reported to CQC as required. For example, one person told us a staff member had put medication in their mouth whilst they were asleep and woke to find tablets in their mouth. This was not reported to CQC as a safeguarding. Another person was found to have unexplained bruising and a safeguarding referral had not been completed. Staff we spoke to knew how to report abuse however, not all staff had received safeguarding training. Comments included, “I’ve not had (safeguarding) training here, but I know what to look out for and how to report it” and, “Not that I can remember (having safeguarding training) but yes of course I know the signs and symptoms and report any abuse to the managers, and if it’s not dealt with properly, I would take it further.”

During our inspection we identified a person with unknown bruising however, this had not been reported by staff. We found no evidence this had been investigated and no safeguarding referral had been made.

The service had a safeguarding policy and safeguarding log in place however, during our visit we found multiple medication concerns that should have been reported to safeguarding and no referrals had been completed. There was no evidence that safeguarding incidents had been audited or any evidence of lessons learnt.

People told us they felt safe with the care received. One person told us, “Yes absolutely safe. They keep the bed rails up and are always in the background keeping an eye on [name].”

Staff demonstrated a good understanding of people's needs and how risks were managed. However, during this assessment we found examples where risk assessments and records of care were not robust. We were not assured the manager new all individual risks within the home. For example, they were unaware of one person who had pressure sores on their heels.

We found people usually had the correct equipment in place, required to meet their needs. This included hoists, bathing facilities, sensor mats and mobility aids. However, we found pressure relieving equipment was not always set at the correct setting. Care plans did not inform staff of what settings air mattresses should be at and this meant the majority of the ones observed were set at medium and not based on people’s individual weights.

Risks to people's health and welfare were not always assessed and managed safely or consistently, placing them at risk of harm or injury. Care plans and risk assessments were not robust and not always followed by staff. For example, one person was at risk of weight loss. The care plan and risk assessment lacked detail on how staff should support the person. There were gaps in the recording of food intake and nutritional supplements to aid weight gain and these had not been in stock for a period of 5 weeks. This put the person at risk and their weight had decreased. Another person had a grade 3 pressure sore on their sacrum and heels. The risk assessment was not detailed and did not inform staff of which cream to apply, when, where or what time to help heal the skin. The person should have been repositioned every 2 hours to prevent further deterioration however, repositioning charts and daily notes confirmed this was not happening every 2 hours. Evidence from our assessment demonstrates a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us that the environment was clean and well maintained.

Managers told us that they were in the process of re-decorating. They also told us of their plans for a dementia garden which they said will have incredible impact for the home.

The environment was tired and required redecoration. For example, there was some water damage following a leak to the living room ceiling. We also found odorous smells on the downstairs bedroom corridor. PPE stations were in place throughout the building and were well stocked. Window restrictors were in place. The grate within the downstairs bathroom shower was broken and loose, posing a trip hazard. This was discussed with management, and this had been fixed by our second site visit.

The service had a risk management policy and procedures in place. The service had employed a full-time maintenance person to have oversight of any work required in the home. We saw records of checks that had been carried out on equipment and the premises. However, call bells were not always in good condition. Some call bells did not have the triangle end to pull or buttons and some were not in reach or accessible to people.

Most people we spoke with told us there were not enough staff to meet their needs and that agency staff were often used. Comments included, “There is no consistency. There is a tremendous turnover of staff. It would be much better if we had the same staff and less agency staff” and, “There are a lot of different staff, some of them are off hand” and, “No, there are not enough staff, they are very busy. At the weekend, agency staff come in, there are lots of them. There are people in the lounge who call out, but they don’t come to them because they are looking after people in their rooms, so the people in the lounge get left. They need to have more staff who know them and what they need.”

Staff told us there were not enough staff to support people. Their comments included, “Been left with two (staff) today on our unit to look after 21 residents. That is to do everything with them, then document and record. I’m really thinking of coming out of care as I feel we have to behave like robots, and we are not robots. We are caring people trying to do our best but it’s never enough” and, “We are simply overrun with work, not even being able to sit for 5 minutes bar our break times.” We looked at the providers rota’s which showed one nurse had worked 72 hours in one week. Managers told us they used a dependency risk tool to determine the staffing levels and were in the process of recruiting.

During the assessment there appeared to be enough staff to support people. The atmosphere was calm, staff were not rushing people and people were seen to be relaxed and smiling. There were enough staff to support people at lunch time with their meals and people received their meals at the same time so they could eat together. There were staff in the main communal and dining areas who were available to support people when they needed it. People who preferred to stay in their rooms did not always have access to call bells for example, not being within reach or handles missing. This was raised with the management at the time who appeared unaware that calls bells were not accessible.

Systems were not effective in ensuring staff were recruited safely. We found evidence of gaps in references, employment history and Disclosure and Barring Service (DBS) information. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with vulnerable adults, to help employers make safer recruitment decisions. Regular use of agency nurses both day and night impacted on the quality and consistency of care people received.

People told us they felt the home was clean and well maintained. Comments included, “They come around and clean my room and bring me clean clothes” and, “Another thing it’s clean in here.”

The management team were clear on the infection prevention and control (IPC) procedures required and their responsibility to provide PPE. Monthly IPC audits were completed to monitor the home. Staff were clear on IPC procedures and told us PPE was available.

We saw staff followed safe practices to prevent and control the spread of infection. Hand hygiene facilities were available and used by staff. Personal protective equipment (PPE) stations were in place throughout the building and were well stocked.

There was an infection control policy and process in place, and we observed staff followed safe infection prevention and control procedures (IPC). Notices about safe IPC practices were displayed throughout the home, such as hand washing procedures.

We received mixed feedback from people and relatives in relation to support provided with medication. People and relatives told us, “Yes, I get my medication, it is alright now. I did make a complaint and it was sorted out” and, “They come and give me five tablets. I don’t know what they are for.” One person shared their concerns around having pain and told us “I have lots of different illnesses, I am losing my sight, so I need help to take them. I have tooth ache and have had it for eight weeks, so I have been taking lots of Paracetamol. They have tried a number of times to get an appointment at the Dentist and I am waiting for one.”

Following the concerns found at the assessment, leaders told us they would carry out a full medication audit and review their medication processes. Not all staff had received a medication competency check to ensure safe administration of medicines.

Medicines were not managed safely. Medication was not always ordered and out of stock for lengthy periods which meant people were placed at risk. For example, one person did not receive their food supplements for a period of 5 weeks and their weight declined. One person was given patches for Parkinson’s. Correct patch rotation minimises risk of skin irritation which in turn could change the absorption rate of the patch. Staff did not follow the manufacture’s guidance to rotate these which impacted the person as they had a rash on their skin. Covert medication was not assessed appropriately to ensure there was no risk. One person was given their medicines covertly in food however, there was no input from a health professional to indicate any adverse effects from doing this. Some people were prescribed Anticoagulant medicines however, there were no care plans in place to determine possible side effects. These included, anticoagulant treatment, what to do if these occur, how to monitor their anticoagulant treatment, the effects of other medications, foods and alcohol on oral anticoagulation treatment and when and how to seek medical help. PRN Protocols did not contain all the necessary information to make an informed choice when administering a PRN. For example, protocols should clearly state if a person has capacity to ask for their PRN or if staff are to monitor for specific signs and symptoms that person usually exhibits. Medication administration records (MAR)’s showed gaps in administration records and no reasons documented when medicines were frequently refused by people. Stocks checks were not always correct and there was no evidence of the discrepancies being investigated. Due to inconsistencies in the recording of stock intakes and outputs it was not possible to complete a comprehensive stock audit. Evidence from assessment demonstrates a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.