Bromford Lane Care Centre

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

Systems to assess, monitor and mitigate risks to people, including risks associated with the environment, support planning and medicines management were not robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Where incidents and safeguarding concerns had been reported, lessons had not always been learned or improvements embedded into practice. The registered manager had not always acted in a timely way when receiving feedback from other health professionals to ensure people received the correct support and treatment. They also failed to ensure all staff had the correct level of training to safely support people within their roles. Staff failed to always ensure people were safe from the risks associated with cleaning products and other items which could cause harm. Staff were not consistently or robustly trained in the event of a fire. The guidance for staff to follow and safe storage and administration of medicines was not robust. The provider failed to ensure controlled medicines were stored as per the Misuse of Drugs Act (Safe Custody) Regulations 1973. We found medicines were not always administered as prescribed. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People's rights under the Mental Capacity Act 2005 were not always supported or understood by staff. There was a blanket approach applied to decisions such as removing all call bells and shower curtains; restrictive practice in relation to smoking and access to outdoor spaces and communal areas; people observed wearing non-slip socks and the use of CCTV in communal areas without gaining written consent or involve people in decisions made on their behalf. This was a breach of Regulation 11 (Consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Recruitment procedures required some improvement.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they knew how to speak up if they had a concern about their loved one’s safety. Most people and their relatives told us they felt these issues were addressed by the registered manager when brought to their attention. However, some relatives told us how they had raised concerns but felt the communication could be improved to help alleviate their worries. We were also told that most people and relatives were kept up to date when any changes occurred around peoples support needs and changes were made in accordance with these.

Staff told us they had received training to help them manage risks associated with people they support. However, we found that some staff who had been employed for a long time had not completed mandatory or refresher training. Some staff we spoke with failed to demonstrate their learning from the training they had received, for example in relation to moving and handling, fire, Mental Capacity Act (MCA)/best interest decisions and Deprivation of liberty Safeguard (DoLS). We observed some staff stepped back and waited for the senior team to provide support following 1 person who fell from a chair. Most staff told us they could make suggestions in relation to peoples support needs and any changes to improve care. One staff member said, “[Name] the registered manager has an open door, if I see that we could put things in place here to improve care and teamwork, I share with [Name] registered manager.” The registered manager understood their duty of candour responsibilities.

There was a system in place to review incidents and take learning from such events. However, we found these were not always shared with the wider staff consistently and were not always embedded to drive improvements. A lack of consistent training and guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. Staff did not consistently report incidents such as when medicines had either not been administered or the incorrect dose had been given. This meant opportunities for learning and improvements to people’s care were sometimes lost or delayed. Additionally, lessons learned were not always shared with staff and embedded into practice to help mitigate future risks. Where people were expressing physical or emotional distress additional support from health professionals was sought.

Some people and relatives told us that the moving in process and getting to know about information and what to expect could be improved. This was predominately in relation to the Emergency Assessment Bed (EAB) unit. Some felt like they had been left without adequate information, which made them anxious.

Care plans for people did not always include key pieces of guidance for staff when supporting people to maintain their independence, choice and preferences. Although staff told us and we observed how they supported and responded to these, the provider had many new staff who were less familiar with people living at Bromford Lane Care Centre. The registered manager told us they would address these shortfalls in the support plans and started to make such changes during the assessment process. The manager of the EAB unit told us how they have worked to build strong relationships with the discharge teams and professionals who support the people using the service to aid a smooth transition when moving out.

One professional we spoke with said, "There have been a lot of changes, some of how commissioners work and how Bromford Lane Care Centre deal with things. Since the manager and deputy manager of the EAB unit have been here for the last few years it works well. Sometimes things don't work well but the partnership working is brilliant, and we all learn together."

Processes did not always ensure staff supporting people had clear guidance on, and awareness of, their individual needs and risks to keep people safe. We found no evidence this had caused harm to anyone. However, the lack of key information and robust care plans placed people at increased risk of inappropriate care and unmet needs. Reviews of people’s needs, and care plans were not robust and inclusive.

Relatives told us they understood how to raise any abuse concerns they may have. Relatives we spoke with told us they felt their loved ones were safe being supported by staff and did not have concerns about their safety. One relative who was asked if they had ever had concerns about their loved one’s safety, told us, “I’ve no concerns about their care, they are getting exemplary care and being very well looked after. They can’t walk and spends time in bed or a wheelchair, they need help with everything. The staff are lovely with them.”

Staff told us they had received safeguarding training and could describe circumstances which would lead to them following the services safeguarding policy and procedure. However, we found that not all staff had felt confident to raise concerns. An incident of abuse took place which was witnessed by another staff member who failed to report it to the registered manager. It was only identified following reviewing CCTV. This placed people at risk of abuse. Leaders did investigate and share safeguarding concerns with the local authority’s safeguarding team when they were identified.

We saw that most staff were aware of the safe processes associated to supporting people with complex needs, safely. This was with exception of the unsafe moving and handling support for 2 people and lack of a timely response when a person fell, which we witnessed. For example, we saw staff supporting a person who was expressing emotional distress, in such a way to reduce the risk of harm to themselves and others. However, some staff took a step back rather than taking the lead. We observed 1 staff member asleep in the chair whilst allocated to support a person who required 1to1 support. The registered manager took immediate action. Fire doors were observed to be propped open on 2 separate days. Fire drills had not been completed consistently for all staff members, including night staff. Staff we spoke with were not always clear on the correct process on hearing the fire alarm and evacuation. This placed people at risk should there be a fire. We found that although Tissue Viability Nurse (TVN) had provided reports on people’s skin conditions, these had not been acted on in a timely way. This placed people at risk of further harm as repositioning was not always completed as per their individual schedules. We found no evidence that the lack of timely responses or missed repositioning had caused further damage to people’s skin conditions. A cook we spoke with was unable to clearly tell us how to provide safe dietary requirements and how these were prepared. This placed people at risk of choking. The provider spoke with the staff and identified there was a need for additional training. When we brought these issues to the registered managers attention, actions were taken to mitigate risks.

Systems and processes to protect people from abuse and neglect were not effective enough, which increased the risk of immediate action not being taken in response to safeguarding concerns. For example, the provider had a whistleblowing hotline so that staff could report concerns anonymously, however, we found this had not been used to protect people from alleged abuse. People's rights under the Mental Capacity Act 2005 were not always upheld, meaning peoples capacity had been assumed and potentially unnecessary restrictions placed on a person. Not all staff and management we spoke with had a clear understanding of people's mental capacity. We saw that all people using the service had varying abilities when making decisions, but not all staff were clear about what this meant for the people they were supporting. For example, 1 staff member when asked about a person they were supporting was unable to tell us about the Deprivation of Liberty Safeguard (DoLS) which was in place for them or what this meant in relation to their freedom of choice and any restrictions which may be in place. There was evidence of best interests’ decision-making for people in some areas of their daily living, however, there was not a consistent approach for those who were subject to restrictions. Where mental capacity assessments and best interest decisions had been completed, they demonstrate how conclusions had been drawn. During the assessment we saw some positive examples of staff demonstrating how they supported people safely. We reviewed safeguarding processes and found records of ongoing and recorded safeguarding incidents. These had been effectively managed and updated with outcomes and actions.

Relatives told us they were contacted following incidents occurring or new risks emerging. They told us they received information about changes to peoples care plans. Those relatives of people who were permanent told us they had been involved with DoLS applications and meetings. However, we saw that risk assessments were not always robust for specific incidents. This meant the person remained at increased risk of harm. Relatives told us they were involved in reviews of their loved ones needs. Permanent people and their relatives told us they received the updated support plans to read and make any comments. There were face to face meetings to involve the people and their relatives. However, we found and were told that this was not always applied to those living in the EAB unit.

Staff we spoke with were aware of risks to people and their role in monitoring and managing these. Staff did not always feel confident in dealing with incidents when they occurred. Some staff told us they could benefit from more training to help build their confidence. We also saw this feedback on the staff questionnaires which had been returned and were awaiting analysis by the registered manager and provider. We saw there were some gaps in training and knowledge of staff. Staff told us how they supported people in a way to encourage independence whilst monitoring the associated risks. The deputy manager told us and documents reviewed detailed how they updated support plans, risk assessments, and where necessary contacted other health professionals to gain further guidance on how to manage risks for people using the service.

We observed areas of the service where people were prevented from gaining access to such as, the dining room which led into the garden. We were told this was due to the risk of items in the dining room. The option of securing items of risk in a locked cupboard had not been considered as the least restrictive option to reduce risks to people. People were supported to access the community and we saw that safe staffing levels were in place to minimise risks to people.

Risks to people had not always been assessed with them or clear plans developed, with accompanying guidance for staff, for managing these. Some people's care plans lacked clear guidance for staff about their role in monitoring and providing a consistent approach. The system for involving people and relatives when assessing, managing and updating risks would benefit from being more inclusive. Care plans for people moving into the EAB unit were initially written by a staff member working remotely and were based on the information shared by the hospital on discharge. Care plan reviews were also carried out remotely and shared with the deputy manager to add missing risk assessment etc. This process did not include people or their loved ones. We reviewed support plans and found most people's known risks had a risk assessment in place. The least restrictive options were not always evidenced with MCA and best interest meetings, although risk assessments had been put in place. A ‘blanket’ approach was applied in relation to the removal of call bells, shower curtains and restricted access or to leave the premises. We found and were told that DoLS were automatically applied for prior to MCA taking place to identify specific reasons for the application of DoLS for those moving into the EAB unit. We were told that some relatives chose to bring in food for loved ones. However, the registered manager had failed to follow the providers own guidance on how this should be risk assessed and managed, placing people’s health at risk from the unsafe storage and management of food products. The provider has a record in place to monitor when risk assessments are due to be reviewed. The registered manager told us they had a management check list to be completed on a daily basis by senior team members to ensure all support needs were completed and the environment was clean and safe.

People and relatives told us they felt safe living at Bromford Lane Care Centre and had no concerns in relation to the environment being unsafe. Most people told us if they raised concerns in relation to the environment they were actioned quickly.

Managers told us they wanted to ensure people were safe. However, they had not always considered if the actions taken, and decisions made were the most appropriate and least restrictive approach to ensure people lived in a safe environment. Staff were able to tell us what actions they would take if they found faulty or damaged equipment.

We observed multiple environmental risks during the assessment. We found no environmental risk assessments in place for some areas of the service relating to ensuring safe environments were always maintained. The registered manager had not carried out a ligature risks risk assessment, although items such as call bells and shower curtains had been removed for that purpose. We saw areas which had fixtures where ligatures could be attached, which were not covered by the CCTV and were in ‘blind spots’ of corridors and private bedrooms. The service also had animals in the external area, all of which had not been risk assessed. This meant people were placed at risk due to poor environmental safety. Although we saw no evidence this had caused harm, there was a potential of harm to people due to disease and germs carried by both the pets and pests. We observed cleaning trolleys were left unattended at times, in areas where people with dementia were living. We observed rooms containing cleaning products were at times left unlocked or codes to open these doors were written either on the door or the door frame. There were also razors left in a bathroom which was accessible to people at risk from known suicidal tendencies. We also found a personal fridge in a person’s bedroom; this did not have a risk assessment in place to manage the correct storage and temperature of food. There was also no guidance for staff to ensure the fridge was checked for out of date food. The deputy manager told us the person would not allow this; however, their care plan did not reflect this. This also placed people at risk of unintentional harm. When we brought these issues to the registered managers attention, some actions were taken to mitigate risks.

Managers had failed to always follow correct processes in the management and safety of people and their environments. This meant people were either unnecessarily restricted or exposed to risks. There were audits and checks carried out in line with health and safety guidelines, to ensure equipment was safe for use. There were maintenance staff working in the home who had a system where staff recorded and reported areas or equipment requiring repair.

People and relatives told us their loved ones were mainly supported by the same group of familiar staff. Relatives told us overall they felt their loved ones were supported by staff who knew them well and recognised risks. However, changes in staffing at times made them feel concerned that staff did not know people well. People were visibly comfortable in the presence of staff. Most people and relatives told us they felt their loved ones were safe. Most people and relatives felt there were enough staff however, we were told by 1 person that they were told to urinate in their pad, by staff even though they were asking to use the toilet. It is unclear if this was due to the staffing ratio to support with this or poor care and lack of respect for the persons dignity. This was shared with the registered manager who told us they were not aware of this but that it would be investigated.

Staff felt the provider employed enough staff to support people safely and spoke about how numbers have been increased or decreased depending on the persons level of support required. Most staff we spoke with told us they had received appropriate training relevant to their role. Some staff said they could benefit from additional training. When we spoke with some staff it became evident that although they had completed training, their competencies to implement their learning into the daily support of people was less effective. Some staff could not tell us how MCA and DoLS applied to people they supported. Staff awareness of the correct process should there be a fire was not robust and kitchen staff awareness of how to prepare food for those with specific dietary needs had not been provided. This was shared with the provider who was continuing to work with the registered manager to provide additional training and guidance to these staff.

We observed that staffing ratios, as per peoples assessed needs were being met. Staff were available to support people when they needed support or guidance. Most staff knew people well. This was demonstrated by the positive interactions and responding to their requests. Based upon our conversations with staff we found some staff would benefit from additional training to understand individual needs and support. For people who chose to stay in their rooms and did not have call bells, 15 minute observations had been implemented. However, alternative, less intrusive options had not been considered or assessed.

The provider had not always ensured staff had completed all the training they needed. The provider’s staff training record indicated staff received regular training in many areas, but there were gaps which needed to be addressed. The provider assured us they were addressing these shortfalls immediately. Competency assessments were carried out for some areas of training. Some of the nursing team, who were the responsible staff members in the absence of managers, had not completed any training at all. The provider has a supervision record to identify which staff had received supervisions. Some staff told us they had not received a 1to1 supervision for a long time and had only attended group supervisions. Staff files did not always evidence that staff members inductions had been completed and that suitable references had been obtained. The providers own staff survey results indicated staff had not always received induction, training and supervisions as per the providers policy. The registered manager used a dependency tool to ensure staffing levels were safe and a rota system was in place.

People told us they were happy with the cleanliness of the home. Staff told us how they cleaned the communal areas and individuals’ bedrooms and actions they would take should they identify any areas requiring repair or replacement.

The main areas of the home were seen to be clean and tidy with housekeeping staff available when needed. Individual pressure cushions were not named to prevent these being used inadvertently for others and to aid the audit process ensuring they are in good order. We were told that spare clothing in the laundry was used for people coming into the service who did not have any belongings. We observed good practices in relation to the safe and correct use and disposal of Personal Protective Equipment (PPE). However, we saw clinical waste on 2 occasions, left in bags on hard floors rather than being taken straight out to the external bin area.

There was a policy and procedure in place for infection Prevention and Control (IPC). There was a daily walkabout carried out by the care coordinators which included checking staff members IPC practices. IPC audits were carried out 3 monthly to ensure standards of good practice were upheld. A recent IPC visit was completed by the local authority IPC team and rated the service good.

Relatives told us overall they had no concerns in relation to the administration of medicines. One relative told us how they were concerned about their loved one’s pain they were experiencing. We reviewed the information available and found the staff had obtained suitable pain relief. We saw that 1 of the controlled medicines cabinets was not secured to the wall using the correct fixtures. Controlled medicines were not always administered with the correct gap between doses. Most medicines we checked had the correct balances although there were several discrepancies, which were discussed with the clinical lead. This meant we could not be assured medicines had always been administered as prescribed. One staff member did not always follow the correct process when administering medicines via Percutaneous Endoscopic Gastrostomy (PEG). This is a tube directly into the stomach for food, fluids and medication. This was not correct or safe practice. The PEG protocol reviewed by our medicines inspector was found not to be robust, which increased the risk of unsafe practice. Medicine patches were not always applied correctly, and records were not always completed to indicate the location they were applied to, as per the manufacture’s guidance. Guidance for ‘as required’ medicines were not always detailed enough with the signs to look for when people may require such medicines. Staff were not always following the correct administration, for example, antibiotics required to be given 1 hour before food was not followed. Staff were not always clear on how to obtain and record the correct temperatures of medicines fridges. We saw that the fridge on 1 unit had been working above the recommended temperature for a period of time without actions being taken to rectify this. The registered manager acted to address the fridge temperature. People receiving medicines were given encouragement and explained what was happening during the administration of medicines.

Staff including nursing staff were unable to demonstrate how to obtain and correctly record the minimum and maximum fridge temperatures. Staff felt they had received adequate training to safely administer medicines. Staff were able to tell us the correct procedures to follow when a medication error occurred.

People were not always supported to receive their medicines safely. The provider had policies and procedures for safely managing medicines, however we found staff failed to always follow these. For example, staff were not always following the providers policy and procedures, or safe practices in the administration of controlled medicines, patches, antibiotics and administration via PEG. Medicines audits were completed each month; however, these had failed to identify the issues we found. People’s care plans contained information about how they wanted to be supported to take their medicines.