Brenalwood 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

The provider was in breach of regulation relating to staffing and safe care and treatment at inspections which were published in November 2022 and in November 2023. At this assessment we have found continuing breaches of these regulations. People were being placed at risk by the provider failing to identify and address breaches of regulatory requirements. The provider had not made sufficient improvements to the safety of the service. This lack of oversight had impacted on the quality of care provided.

There were not always enough staff on shift to ensure people received person centred care or that their holistic needs were always met. Records did not always demonstrate satisfactory pre-employment checks were completed and documented when staff were recruited to work in the home. This meant the provider could not be assured they were suitable to work with vulnerable people. This was a repeated breach of regulation 18: Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risk assessments relating to people's daily lives lacked detail and were not always reflective of people's current needs. Guidance for staff about how to manage and mitigate risk was not always sufficiently detailed and the system for assessing risk was not robust. The service had systems in place for appropriate and safe handling of medicines, however staff were not always following these. This was a repeated breach of regulation 12: Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a robust method of keeping people’s representatives updated with important information about their family member’s care and welfare. Some relatives told us they were not told when, for example their family members had received health care support or there were changes in their wellbeing. Some relatives told us when they had shared concerns with the management team, they were not always given an update as to what actions had been taken. Therefore, they were not certain that their comments had been addressed and used to drive improvement.

The service had not demonstrated a learning culture where the provider had implemented measures to ensure people received safe care at all times. The provider had failed to learn lessons from previous inadequate and requires improvement ratings and breaches of regulation. Not enough improvements had been made in the service since our last inspection, and the improvements that had been made were not sustained. During this assessment, we found a deterioration in the service which placed people at risk of receiving unsafe care.

Prior to our assessment we had received concerns from the local authority about the service provided and risks to the safety of people. The management team told us they had been made aware improvements were needed and the local authority were visiting the service at least weekly due to their concerns about the service. The management team told us they were working with the local authority and had an improvement plan in place. The concerns identified by the external professionals had not been independently identified and addressed by the provider.

The management team told us they had systems in place to learn lessons from incidents and accidents, which were disseminated to the staff. However, we found the systems in place were not robust and inconsistently implemented. This had led to a deterioration in the service provision and continued breaches of regulation.

We were not assured the service had robust systems to learn lessons, this included in relation to staffing, safe care and treatment and good governance. We had previously noted breaches of regulations in these areas in 2022 and 2023. The service had not implemented and embedded improvements, and those improvements made had not been sustained. Therefore, during this assessment we found the provider had not taken the necessary actions to improve and remained in breach of regulation.

The processes in place were not robust. For example, the management of medicines was still not safe, since our last inspection. There were errors on people's medicine administration records (MAR) but there was no documented investigation into these. This meant themes and patterns had not been identified and no improvement had been made. There was no analysis of events to identify trends and there was no evidence of how lessons learnt had been used to facilitate improvement in service delivery.

There was an inconsistent approach to how lessons were learned and documented relating to safeguarding. For example, only 1 of 26 entries on the safeguarding log included what actions were put in place to mitigate future risks. There were some records of recent specific safeguarding incidents. These included actions taken, notices provided to staff, and a staff meeting in September 2024 which detailed how lessons were being learned. However, previous staff meeting minutes did not always detail the lessons learned and give staff an opportunity to discuss. This was a missed opportunity to reduce risks of a reoccurrence. There was a topic reading file, which included actions required from staff and some lessons learned, these were not always dated.

Although accidents and incidents had been recorded it was not always clear what action the provider had taken to address issues or how lessons learned had been used to develop and improve the quality of care provided.

We received mixed feedback regarding the support people were provided with when they moved between services. Some relatives told us their family members were assessed prior to moving into the home. For example, a relative said, “Before our [family member] moved to Brenalwood, they took the time to visit [family member] in person at [their] previous care home… and also consulted with the carers there to establish [family member’s] needs, level of care required, especially as [they have] dementia. And we were given ample opportunity to look around Brenalwood ourselves and ask questions.” However, we also received feedback that people had moved into the service in short notice and they and their representatives had not always been consulted about their family member’s care needs.

Prior to our assessment we received a concern from a person’s representative when they had been admitted to hospital, unclean clothing and clothing which did not belong to their family member were provided, which was not dignified.

Some relatives told us they were not always kept updated about their family member’s wellbeing and if they had received healthcare treatment.

The manager told us assessments were undertaken prior to people moving into the service. However, we were not assured the assessments were used effectively to inform the care plans and risk assessments. We found people’s records were contradictory and not kept updated to reflect people’s current needs and preferences. Whilst we found, for example, a person’s records referred to what the hospital staff had told the service about the person and their needs, their care plan had not been reviewed and updated to show their current needs and preferences. Another person’s care plan had not been kept updated to show the outcome of tests undertaken by external health care professionals. This could lead to people receiving unsafe and inappropriate care.

We received concerns from social care professionals relating to people’s safety and the care provided. This included concerns relating to safe pathways and transitions to, for example people’s admission to hospital. Some people were not returning to the service following their hospital stay due to concerns.

People’s records did not demonstrate they and their representatives, where appropriate, were involved and agreed with their care plans and risk assessments. There were no records of reviews with the person and their representative, to show these were being kept up to date. This was important to ensure good quality and safe care, and if a person was required to use a service, such as a hospital, the information held about the person was not current. This could lead to inappropriate and unsafe care.

There were ‘this is me’ documents in place, whilst these did show they were done with the person using the service, they included minimal information about the person. These documents are usually used to go with a person, for if they needed to be admitted to hospital, to give important information about the person, their preferences and needs. This could lead to the provision of inappropriate care when a person moves between services.

Prior to our assessment, we had received concerns from social care professionals relating to the safety of people using the service. This included not keeping people safe from harm and not always reporting incidents which may have reached the safeguarding threshold for external investigation. There were ongoing safeguarding enquiries in progress. Due to the concerns identified by the local authority, they suspended new placements into the service until improvements were made.

People told us they felt safe living in the service. We received feedback from a relative who said they had witnessed on many occasions people being told to sit down by staff when they were attempting to stand, which deprived them of their liberty. This was confirmed by social care professionals who had noted concerns about staff’s approach when people attempted to stand. The manager told us they had spoken with a relative recently about this issue, and noted the people were people at risk of falls and it was not safe for them to stand without staff support.

We received mixed comments from relatives if they were kept updated about their family member’s wellbeing and safety.

Prior to our assessment visit the local authority informed us of a safeguarding incident they were in the process of investigating at the service. The management team told us the actions they had taken after being informed of the concern by the local authority in September 2024. This included suspending the staff involved and meeting with the remaining staff to remind them of the safeguarding and speaking out policies and procedures, and to reassure them any concerns would be listened to and acted on.

The operations director provided us with some root cause analysis for recent safeguarding concerns, which included lessons learned. We saw the lessons had been disseminated to staff in a meeting in September 2024. However, previous staff meeting minutes did not show safeguarding concerns were always discussed and staff were updated on their roles and responsibilities, including lessons learned to reduce future risks. This demonstrated an inconsistent approach to how lessons were learned from safeguarding incidents.

A staff member told us about a person who was at risk of self harm. Their records did not identify this, nor specify their mental health status. It was not clear what the condition was and when and how staff were to provide this support to reduce the risks of a deterioration in the person’s wellbeing. The records lacked detail of the risks associated with the person’s mental health and mitigating measures in place to keep them safe.

Staffing levels were not always adequate to meet the needs of people and keep them safe from harm. There were not enough staff to ensure people were engaged to occupy them and minimise the risks of potential incidents or distress resulting in harm. Although staff were present in communal areas, they were busy and had little time to provide meaningful engagement, and to ensure people who chose to spend their time in their bedrooms were engaged. This meant the service provided a task led service rather than ensure people’s holistic needs were always being met. This was also evident on people’s daily notes which provided evidence of little engagement provided to people outside planned activities.

There was a safeguarding notice in the service which provided information of how to contact the local authority if there were safeguarding concerns.

Staff had received training in safeguarding. However, we received information from the local authority that staff were not always aware of their roles. Although we saw recent staff meeting minutes from September 2024 where a safeguarding incident had been discussed and lessons learned disseminated to staff, other meeting minutes showed staff were told when there was a safeguarding enquiry, but they were not always advised of how to reduce risks going forward.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

The manager told us DoLS applications had been made for all people who used the service. However, some were not yet approved. The care records we reviewed did not include details of the DoLS applications, and how this may impact on restrictions of liberty.

There were mental capacity assessments in place relating to people’s care, however, these were not always fully completed, including the dates people’s representatives were consulted with in the person’s best interests, in addition some people's next of kin were incorrectly referred to. Some of the records referred to another person’s name and gender, which did not demonstrate these were person centred.

We were concerned people were not receiving the support they needed with their oral care to maintain good health. We noted a person’s teeth and tongue were discoloured. A staff member told us this may be due to the person chewing their medicines. This was not identified in their care plan. People’s care plans did not always detail the support people required with their oral health and daily records did not always evidence people had been supported to brush their teeth.

A relative told us their family member had been itching for some weeks, and the service had not told them nor their family member to update them on the treatment being provided. They told us they had been informed by external professionals that there was an outbreak of scabies in the service, which they found distressing because they had not been kept informed.

Prior to our assessment we had received a concern from a person’s representative that their family member had not been supported to drink enough and they were dehydrated. During our visits we saw people were offered drinks. However, people’s care records included a target for their fluid intake to reduce the risks of dehydration. The records of drinks provided did not always show the person had that amount each day, or were always offered the recommended amount of fluids. There was limited detail in the care records to show when staff should be concerned if a person had not taken enough fluids, or the signs and indictors of dehydration.

We received mixed views about the safety of the service. One person said, “I had falls at home and couldn’t put on my family. I feel safer here.” A person’s relative said when they visited the staff popped their head into the door of bedroom every hour or so, they were confident checks were being done." Another person's relative told us they felt the service provision had deteriorated.

Some staff told us they knew about potential risks to people’s safety. We found, however, that people’s care plans and risks assessments were not consistently up to date and did not always contain essential information to keep people safe. This was particularly important because the service were using agency staff at the time of our assessment, who would not know the people as well as permanent staff. This places people at risk of receiving unsafe care.

During our feedback of the assessment, the manager told us there had been some people in the service who had a rash and/or were itching. They had taken appropriate action in seeking health professional guidance, it had not been confirmed that the issue was scabies and no diagnosis had been provided, but treatment had been prescribed to eliminate the risk. However, due to feedback received, relatives had not all been kept updated.

There were not enough staff to keep people safe at all times. We saw staff were present in communal areas to support people where needed. However, we did not observe people being encouraged to and supported to move position to reduce pressure injury, when they had been sitting for some time, apart from when they moved to another area, such as to use the bathroom.

People’s records did not always detail the support people required to reposition to reduce the risks of pressure injury, although the frequency was provided, they did not detail, for example for the person to be supported to different positions, or what positions the person found comfortable and uncomfortable. There was little detailed information about how and if people were supported to reposition during the day when they were in communal areas.

We had received concerns from the local authority where they had witnessed inappropriate moving and handling techniques used. We saw staff meeting minutes in September 2024, where staff were advised they must use safe moving and handling and updated training would be provided. During our assessment, we did not witness unsafe moving and handling.

We saw a person had spilled a drink, staff quickly identified this, cleaned it up and placed a notice identifying the floor was wet, to reduce the risks of falls.

Risk assessments were often generic in detail and in some instances did not accurately reflect the needs of people. Care records did not always contain guidance for staff about how to mitigate risks to people’s daily lives, including risks associated with distress, nutrition and mobility. Some risk assessments and care plans referred to the incorrect gender and name of the person, demonstrating they were not always person centred.

People’s records had inconsistencies and contradictions, such as a person’s records stated they were to have a level 6 food and level 5 in the same section. There was no date included when this guidance had been provided by the Speech and Language Therapy (SALT) team. This could lead to unsafe care.

Another person’s records showed they had a fall in January 2024 and the hospital had undertaken tests as they considered the fall may have been a result of the person’s medicines. The records had not been updated to show the test results nor measures taken to reduce risks following January, placing the person at risk of harm.

A person’s records stated they mostly preferred to sleep in a chair in the dining room rather than their bed. Whilst their records referred to the safety measures when the person was in bed, such as a sensor mat and hourly checks, there was no information to show what measures were taken when the person slept in the chair. The manager told us staff were always present in the area where the person slept which reduced risks. However, we were concerned this would leave only 2 staff available at night to support other people.

A person’s records included information about a pressure injury, this was not updated in the care plan since June 2023 to give detailed information about the current status of the pressure injury. The safeguarding log did show pressure injury in 2024. It was not clear if this was a recurring, new or old injury.

Prior to our assessment we received feedback from the local authority about their concerns about the safety of the environment. This included wheelchairs and equipment being left in people’s bedrooms, which were a hazard. For example, in a person’s bedrooms there were 3 wheelchairs, not all belonging to the person. This had not been independently identified as a risk by the service and addressed prior to it being pointed out by external professionals.

A person told us, “I do get asked by staff to go into the lounge, but I prefer my own room.” When we asked if the person liked their room they answered, “It’s a room isn’t it?” A person’s relative told us they felt their family member’s bedroom was small, and as they spent a lot of time in their bedroom, they would prefer a larger room.

There was ongoing redecoration of the service. The manager told us how the maintenance staff was working through the building to redecorate. All of the corridors had been painted the week prior to our first visit, some rooms had new double glazing and the maintenance staff member was working through the bedrooms. They told us there was work being done to improve the signage on people’s bedrooms doors to assist them to identify where their bedrooms were and to support people to personalise their bedrooms more. This was due to concerns raised by external professionals.

At the time of our feedback to the assessment on 18 November 2024, the manager advised the signage to people’s bedrooms had not yet been completed. They said people’s families and people were being consulted about the signs to go on their bedroom doors. The manager told us an updated fire risk assessment had been completed 15 November 2024 with no actions required.

Additional crash mats and sensor mats had been ordered following concerns raised by the local authority and staff had been advised to ensure they were in the correct positions and plugged in. The manager told us they were in the process of ensuring the wheelchairs used by people would be labelled with their name. We were concerned some of the improvements being made had not been independently identified and addressed by the provider, until they were pointed out by external professionals.

Since our last inspection, we saw there had been changes to the seating arrangements in the lounge and dining area, which provided different areas people could choose to spend their day and have visitors. However, on the ground floor there was only one large shared area which acted as a dining room, lounge and a room for activities. This reduced the options for people accommodated on the ground floor, who may wish to for example, watch television in the communal area, when there were visiting entertainers. On the first floor there were some shared areas people could use, for example seats and a window bench in 1 area and another had seating and bright coloured pictures on the wall. None of these areas on the first floor were being used by people during our visits.

There were areas in the grounds where people could use in the better weather, we noted some had artificial flowers, the operations director told us that in the winter the artificial flowers were used to keep the garden looking nice and colourful for people to see.

People’s records did not consistently provide information about the equipment people used, which could lead to people receiving unsafe care. For example, a person’s records stated they used a frame to mobilise, however, there was a risk assessment in place for the use of a wheelchair. Another person’s records stated they were supported to wash in bed, but there was a risk assessment in place for the use of a shower chair. This could lead to people being supported using inappropriate equipment which placed them at risk.

Records showed equipment and the environment was checked to reduce risks. This included fire safety, moving and handling equipment and legionella in the water system. We reviewed the previous fire risk assessment which included actions taken following recommendations.

Audits had not been used effectively to support the provider to independently identify and address shortfalls in the environment and had not identified the risks and concerns external professionals had.

Prior to our assessment, we received concerns from the local authority regarding the staffing levels in the service. We were told the service had increased the staffing levels to include a ‘twilight’ shift and a staff member starting work earlier in the mornings. The evidence gathered at this assessment demonstrated the staffing levels were not sufficient in meeting people’s identified care needs.

We received mixed views relating to staff being available when needed, with several relatives telling us they felt there were not enough staff in the service. A relative told us their family member was distressed when they had to wait for 2 staff to assist them to use the toilet, resulting in them having to use their pad.

Relatives also told us their family members were bored when the activity staff member was not on duty. There was only 1 activity staff working in the service, they worked during the day, there was no activity staff in the evenings and weekends. The staffing levels and our observations did not show care staff had time to support people with social engagement, including people who chose to spend time in their bedrooms. A relative told us, “There is no time for staff to sit and chat with [family member], [family member] just spends time in [their] room doing puzzles, it is so sad.”

We received feedback from some relatives about the caring nature of the permanent staff, but some were concerned about the use of agency staff who did not know their family members well. At our last inspection we noted improvements made in the reduction of agency staff used, at this assessment we found the service were again highly reliant on agency staff.

Staff told us how they felt there were not enough staff working to provide people with the care and support they wanted to. A staff member told us that the mornings were particularly busy and the lack of organised staff allocations meant it could chaotic, with staff going to support some people who had already been supported and some people not being supported until 11am to get ready for the day. A staff member said, “We need more staff do not have enough time.” Another staff member said, “A lot of people have dementia, it takes a lot of time to support them, cannot be a tick box.”

The manager told us they were in the process of recruiting additional staff. This included senior night staff, there was no senior cover on during the night, which meant staff were not trained to provide support to people who required support with medicines. The manager told us the manager and deputy manager were on call and could attend the service if required. In addition, a care staff member was in the process of being trained to undertake the senior role. The manager told us the agency used had recently been changed, who were more reliable.

Some days catering staff worked until 8pm and some days 2pm. The management team told us when the staff member worked until 8pm they assisted the staff with suppers, however, we were concerned when the catering staff finished work at 2pm, it took care staff away from their caring duties to support with supper. The management team told us this was supported with the additional twilight shift recently introduced, however, the twilight staff was on duty every day and introduced due to concerns raised by external professionals.

There were no probationary reports in place in staff personnel files, the regional director told us these were not undertaken, but 1 to 1 supervision meetings were held. In addition, they spoke with newly recruited staff when they visited about how they were getting on in their role, but these were not documented.

We saw staff were available in the shared areas to support people. Although staff were caring in their interactions, they were busy supporting people with their physical care needs. This meant the care provided was task led. There was little time for staff to spend time with people to meet their cognitive needs, such as sitting to chat with them, despite this being identified as a need in a person’s care records which we reviewed. Daily notes did not always show that staff engaged with people, outside of the planned activities. There was some reference in some records which referred to a 2, 5 or 15 minute chat, but these did not detail what the chat was about and how the person presented. Some records showed there were 3 consecutive days when there was no interaction recorded.

The numbers of staff available to support people were not sufficient to ensure people’s needs were always met. The service used a dependency tool to assess the numbers of staff needed to meet people’s assessed needs. We found people’s records and dependency needs were not always accurate. For example, a person’s care records stated they were both medium and high dependency in 2 different records. People’s care plans and assessments were contradictory in parts and did not always reflect their individual needs.

A person’s care plan stated they got up during the night, but also said they slept well, and their dependency assessment said they slept all night. Another person’s records stated they could use their call bell for assistance, but also said they were unable to and required hourly checks. Therefore, the records did not provide accurate detail to undertake a robust assessment of the staff numbers needed.

During our feedback, we told the management team the staff rota did not always include the hours staff worked and found where an agency staff member was on the rota for 2 full days including the night shift in between. The management team told us this would not be correct and a further rota was sent to us. The times had been added to the shifts and showed the agency staff had worked a shift of 36 hours. Following our assessment, the provider sent us documentation to show the hours agency staff worked, which was not the hours reflected on the 2 rotas.

At our last inspection we made a recommendation about safe recruitment. At this assessment, we reviewed 3 staff recruitment records and found shortfalls. This included for 1 staff member their application form was not fully completed, no contract, no interview notes and a lack of documentation to show original identification had been seen. The manager did tell us this was being addressed. The references had not been verified for the second and the third held no contract and undated interview notes.

People and their relatives were mostly positive about the standards of cleanliness at the service and confirmed they saw staff wearing personal protective equipment (PPE).

A relative told us, “[Family member’s] room is spotless, I sometimes pull back the covers and the sheets are always clean.”

However, prior to our assessment we received concerns from a person’s representative where they had been provided with unclean clothing when they were admitted to hospital. We also received concerns from the local authority where they had found an unclean bathroom and omissions in the cleaning schedules.

The manager told us they were waiting for recruitment checks for a part time domestic staff member, for which they had been waiting for over a month. During our assessment feedback, the manager told us they were adding additional staff to the rota, sometimes agency staff to assist in the cleaning of the service, including deep cleans. We were concerned there was only 1 domestic staff working in the service, when there were 30 people using the service who needed their personal and shared spaces cleaned effectively and have their laundry taken care of. The management team told us some domestic duties were undertaken by night staff, including putting the washing machines on.

The provider told us in their Provider Information Return (PIR) that staff received training in infection control which was confirmed in records. There was an infection control champion in the service. The operations director told us training had been sourced for champions and was due to be rolled out in December 2024. They said that previous training had been provided, but needed updating due to changes in champion roles and staff.

The communal areas were visibly clean, however, we saw a person had asked for a table, which was provided but this had not been cleared of used cups, nor cleaned. This did not demonstrate good infection control processes.

The local authority told us they had noted people were not being supported to wash their hands before meals, this was also our observations. In addition, we had seen a person in their bedroom who had just finished their meal and they had unclean nails. The manager advised this person was supported by the activities staff member to clean their hands and nails. We saw reference in daily notes to support being provided to some people referred to as a ‘pampering session’.

We saw personal protective equipment (PPE) was available and used by staff. However, staff used gloves to support people with their medicines. Best practice is for staff to wash their hands whilst supporting people with their medicines.

There was only 1 domestic staff member who undertook the cleaning of the service and there was no laundry staff member. At our last inspection we had noted the previous inspection had highlighted an additional domestic staff member had been employed, but this had not been sustained, there was 15 people using the service at that time. During this assessment the numbers of people using the service had doubled and there remained 1 staff member. Some duties, including putting laundry in machines and other domestic chores were undertaken by night staff, as well as supporting people with their care needs.

There were cleaning schedules in the service, however, we saw the ground floor bathrooms had missing signatures to show it had been cleaned. This bathroom held a person’s personal toiletries, these were moved immediately and we were told by the management team the person had only just finished using the bathroom.

People were not always receiving their medicines safely or as prescribed. Stock levels of people’s medicines were incorrect indicating people had not been given their medicines. People’s medicines administration records [MAR] weren’t always updated when changes to doses of their medicines were made or their health needs changed, for example, if they needed thickened fluids. There was not a robust system in place to ensure people who were prescribed time specific medicines had their medicines at the same time each day.

People’s care plans for medicines were generic but contained some specific information about the individual, their care and treatment and their personal preferences. When required [PRN] protocols were in place but did not always contain person centred information. There were no records in place to document where staff were applying hormone replacement patches which have specific instructions for use. This meant people may not receive their medicines safely. Where people received PRN medicines, there were no records documenting why these had been given and if the medicines had been effective. Where people experienced distress and agitation, staff were not recording what techniques they had tried first to support the person before they gave medicines. The manager provided assurance from their observations of staff supporting people using distraction techniques. People had access to healthcare professionals for specialist support such as diabetes care. There were risk assessments in place for medicines that caused an increase in bleeding and bruising and fire risk assessments for paraffin containing emollients.

A person’s relative told us they had noted their family member was sleepy and they had told them they had been given their sleeping tablet earlier than they preferred. They told us they had raised this with management and was told this would be looked into.

The service was in the process of recruiting and training new staff however, there were no staff working at night who were trained to give medicines. The manager and deputy were on call to administer medicines if needed during the night to ensure people did not go without their medicines. Staff had received training for medicines management and optimisation. Competency assessments were completed regularly however, we were not assured all staff were competent to give medicines due to errors we found during the assessment.

The systems in place to monitor the administration and recording of medication were not robust enough to keep people safe. Medicines were not always administered or stored safely. Staff were not always completing stock counts of medicines or recording these correctly and therefore missed doses had gone unnoticed. The medicines room was lacking in space and items such as cigarettes and batteries had been stored with medicines and paraffin containing emollient creams which was a fire hazard. The fridge thermometer had been recording a maximum temperature above the recommended temperature for storing medicines for the whole of 2024, but no action had been taken to rectify this. We could not be assured medicines had been stored at the correct temperature and remained safe to use. Audits were being regularly completed however, they had not identified any of the concerns we found during the assessment.

Prior to our assessment, the local authority told us how they had concerns with the safe management of medicines, this included the records maintained when people received their medicines that were, for example, hidden in food. During our assessment, we found the service had contacted external professionals to address the issue, however, we were concerned this had not been independently identified and addressed by the service until external professionals pointed it out.