Braywood Gardens

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• 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 we assessed all quality statements in the safe key question. We found safety concerns, which have resulted in a breach of regulation for: safe care and treatment and safe staffing. People did not feel they were safe from abusive care. We saw that people were at risk of neglect due to a lack of staff. The management team had not taken sufficient action to keep people safe and refer to the external safeguarding team after people had been in altercations with each other. Safety risks to people were not managed well. People were at risk of their health needs not being appropriately supported, pressure related skin damage, poor moving and handling, and choking on the wrong texture diet. External health professionals had been contacted, but their advice was not always clearly recorded for staff to follow. There was not enough staff to support people with their needs. We found people calling for support and staff were not available to support them. Inspectors had to intervene to keep people safe. There were safe recruitment checks in place to ensure suitable staff were employed. The environment was mostly safe. However, we did see concerns with cleanliness. There was also an unlocked cleaning cupboard. The contents of this could result in harm to people. Medicines were not always managed safely. People did not receive their time specific medicine at the same time each day. Staff did not always have clear guidance on when to administer ‘as needed’ medicine. One person required daily pain relief, but staff were only administering it when they felt it was needed. They were not recording their reasoning for going against the prescription. This risked the person having unmanaged pain.

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.

People told us that they did not always feel listened too. They told us of concerns they had raised to the staff team. They then either said, “nothing happens”, or there was a lack of communication on outcomes.

One staff member referred to people having “granny fights, where they fight with their zimmer frames.” This is not a dignified way to describe incidents that occur at the service. Staff were able to describe how they would provide support if people came into a physical altercation. Staff told us that if they had concerns about an incident, they would report this to the senior team to make improvements in the future. We were not assured that this communication would result in effective learning. This is because of poor record keeping by staff.

Due to staffing concerns at the service, we observed that staff were not always present to see risks related to people. For example, we observed two service users becoming agitated at each other, with one being verbally aggressive towards the other. No staff were present to observe how this incident had developed, or to see that the incident had occurred. This lack of observation meant risk with these two people would not be monitored, therefore risking repeated incidents. When staff recorded what incidents occurred, their documentation did not include enough detail. For example, when two people at the service became agitated and started a physical altercation, staff had written ‘de-escalated the incident’. They did not describe what techniques were used to de-escalate this incident. Clear recording of what techniques were used would allow learning on what approach would be most effective if they are required again in the future.

People told us that staff would support them to contact health professionals as needed. A relative said, “Any health concerns, they’ll call the doctor. They’ve seen the optician here and has the chiropodist.”

The registered manager explained that the care home took part in a falls pilot scheme. This allowed for a more timely transition to healthcare services after a person had a fall. We observed incidents related to falls were recorded and action taken.

Before the assessment, we received some concerns from external health professionals. These included poor medicine management, risks with skin integrity, and cleanliness concerns. They advised these concerns had already been feedback to the management team. During the assessment, we identified that these risks were ongoing. Therefore, there has been a lack of effective action after professional concerns have been raised.

We found that there were not always safe systems in place to ensure safe working with external agencies. For example, some people had difficulty swallowing their food. As a result of this, a speech and language therapist had prescribed specialised diets to prevent the risk of choking. This prescribed need were not clearly written down for staff to follow, therefore there remains a risk of people choking on an incorrect diet.

People did not feel they were kept safe. The service supported multiple people with mental health conditions. People explained that these people would often walk into their bedrooms, and this caused them anxiety. One person said, ‘A person kept coming into my room and took my things. They sat on my bed. It was scary.’ Documentation showed that there had been no risk assessments on how to keep this person safe from others going into their room in the future. Several people told us that staff were not gentle when they provided personal care support. One person said, ‘I have help with showering and they can be a bit rough handling my private parts. I don’t get asked if things are ok with me - they just do it the way they do it.’ Another person said, ‘The carer this morning was so rough - I wasn’t feeling well anyway and spoke up but got no apology. They didn’t let me choose my clothes - so rushed.’ People and relatives told us that staff could be neglectful in their care. This included, leaving them with drinks out of reach and not providing support when they called for help. One relative said, “They need to use a straw to drink and sometimes we find them without. Sometimes we’ve found that their hearing aids have been put in upside down. Or not put in at all.”

The registered manager explained that staff safeguarding training was nearly 100% completed. We saw that this staff training had not resulted in safe care for people. As a result of our concerns, the management team said they would review staff safeguarding skills at the service. Staff told us that they knew how to identify safeguarding concerns and report them to the senior management team and external stakeholders. Feedback from people, and written documentation showed that people remained at risk of abuse despite staff saying they have the necessary knowledge.

We saw people were at risk of neglect. People shouted for support, or pressed their call bells and did not receive a timely response from staff. Some people had drinks out of reach which effected their ability to drink independently. Others had call bells that were not accessible to call for support.

Incidents were recorded that showed people had been in physical altercations with each other. These incidents had not been referred to the local authority safeguarding team by the provider. This means these incidents of physical abuse had not been investigated by an external stakeholder. We raised this with the provider, who then made these referrals. They advised they would review staff skills to ensure that referrals were made in a timely manner. Staff had written down that they saw two people ‘passionately kissing’. These two people were known to have advanced dementia, and difficulty making decisions. This had not been referred to the local authority safeguarding team and the people’s care plans had not been updated on how to support their sexual decision making in future. This poses a risk to staff not having guidance on how to respond to future risks and incidents. Some people at the service had a deprivation of liberty safeguard in place (DoLS). This is a lawful procedure to deprive someone of their freedom and liberty when they cannot agree to care. Staff did not have clear care plan guidance on how these authorisations impacted the person and which professionals were involved. Where people had conditions assigned to these authorisations, these conditions were not recorded, so we were not assured that staff were following them. For example, one person’s DoLS was authorised on the condition that any objections to their care would be reported to their family. This detail was not in the care plan for staff to understand and action. This meant if the person objected to living in the home, staff may not be aware of the need to report to their family.

People felt that they were not always kept safe, due to the lack of staff at the service. People felt that staff were rushed in their support, or did not respond quickly enough to them.

When we spoke to staff, they did not always have a good understanding what care plan guidance was in place. For example, one person’s care plan described that they ate a normal diet. Staff did not know this and explained that the person required a soft diet. We saw them providing the person with a slice of toast, which would have been a choking risk if they had needed a soft diet.

We saw risks were not always well managed. This was due to a lack of staff at the service. For example, we saw some people were at risk of falls as staff were not present to see them become unsteady on their feet.

Staff did not always have clear guidance on how to keep people safe from harm. This included a lack of guidance on what diet people needed to prevent choking, what equipment people needed to help them move safely or how to support people’s physical health conditions. Where guidance was in place, staff did not always follow it. For example, one person’s care plan said they had a daily goal of how much they should drink, and if this was not followed for 3 days then staff should refer to their GP. Records showed this person had not met this hydration goal for 17 days, and no referral to the GP had been made. This put the person at risk of their dehydration not being responded to safely. People were at risk of skin damage by unsafe repositioning processes. Notes kept by staff showed people were repeatedly positioned onto the same side (instead of moving them to relieve pressure). People needed two staff to move them safely with equipment, however only one staff member was recorded as moving the person ‘by hand’. This would not be safe for the person. One person had a severe pressure damage injury on one side and professional guidance was for them not to lay on that side. However, records showed they had regularly been in that position, including one occasion for 6 hours. This position is likely to be very painful for the person and could cause further damage to the person’s skin.

People felt that the environment was managed safely.

Staff and leaders felt the environment was kept safe. The registered manager explained there was a dedicated housekeeping and a building maintenance team to keep the environment safe.

We observed the housekeeping and building maintenance team working hard to keep the environment safe for people. For example, the building team was repairing and painting damaged woodwork. This painted surface can be more easily cleaned to prevent bacteria building up.

People at the service used pressure relieving cushions. These are specially designed cushions, created to allow an even distribution of pressure and help prevent skin damage. Audits were in place to review the safety of these cushions. However, these audits did not always have the date written down. We were therefore not assured that there was a suitable checking system in place for this equipment. We saw an unlocked cupboard with hazardous cleaning material in. Not locking this cupboard poses risk to people coming to harm by touching or swallowing these chemicals. Processes were in place to ensure people were safe in the event of a fire. Processes were in place to ensure that people were protected from Legionnaires disease. Legionella is a serious waterborne disease that can build up in water systems that are not managed safely.

Every person and relative we spoke to expressed concerns with the amount of staff in the care home. They explained that staff were rushed, did not respond to call bells quickly, and these delays left people in unsafe and undignified states. People and relatives particularly expressed concerns about the lack of staff available at night and at weekends. One person said, “What’s the point in pressing the call bell as no one comes. I pressed a few weeks ago for some help in the bathroom. I waited an hour, so then just turned it off and tried myself.”

The registered manager told the inspector that they used a calculation tool to calculate how many staff hours each person needed to keep them safe. This then calculated how many staff were needed in total for the service. The registered manager explained they were confident in this tool, and felt the service was ‘over recruited.’ We reviewed this tool and found it was poor quality as it did not assign enough staff hours for people’s needs to be met. We were therefore not assured by the registered managers feedback on how staffing was overseen at the service. Some staff felt there were not enough staff. One staff member said, ‘There are 5-6 residents who need support with feeding, and only 2 or 3 staff. We try our best, but it can be hectic.’

There were not enough staff to support people safely. We saw that communal areas often had no staff in for prolonged periods. Members of the CQC assessment team intervened to repeatedly support people to remain safe. For example, one person attempted to stand but was clearly unsteady on their feet. There were no staff to observe or support this person. The inspector needed to support the person to sit down again. If the inspector had not supported the person, they would have likely fallen over. When the inspector called for staff support in this situation, the staff responded they were “too busy.” People did not always have call bells within their reach. When they did have access to a call bell, staff were not quick to respond to these bells being pressed. For example, a person shouted the inspector saying they urgently needed the toilet. The inspector noted that the person had already pressed the call bell, however 20 minutes later staff had still not responded to the person‘s call bell (or shouts for help). Another person was shouting for help, and we saw they had pressed their call bell. A staff member came into the room and turned the bell off. They provided no reassurance to the person’s anxiety and did not ask why the person needed help. They said they would return later. The inspector noted they had not returned within 20 minutes and the person had remained distressed.

The service was separated into different units. Within each unit there were multiple people that required two staff to support them to move, go to the toilet or reposition. For example, within one unit there were multiple people who required two staff to support them. There were only 2 staff allocated to support these people. When these two staff were supporting people together, it meant the remaining people in that unit had no staff to observe them or respond to call bells or requests for help. The system for call bells in the service was not effective and safe. When call bells were pressed in the care home, the alarm was sent to a unit on the wall. Staff needed to walk to this unit to see where call bells were triggering from. This meant they may have to walk past the bedroom with the triggered alarm to see who needed support, delaying support to a person requiring it. The call bell system was not always clear which areas staff should attend. For example, a staff member saw that this central unit had ‘primrose unit bathroom’ as an active call bell. However, we saw they needed to check multiple communal bathrooms on the Primrose unit to see which one has an active alarm. This lack of clarity on the alarm system can delay a timely response to someone needing support. Staff were safely recruited; we saw staff had a Disclosure Barring Service (DBS) check to ensure they had not got a criminal history that would impact the safety of people at the care home. References were also gathered from previous employers to ensure staff were of good character.

People and relatives felt that the home was kept to a clean standard.

The registered manager explained that they complete a daily walk around to ensure the home is of a clean standard. We reviewed these records and noted that the registered manager had previously identified cleanliness concerns and taken action to make improvements. Staff told us that they usually have enough access to personal protective equipment and cleaning products. They explained that there had been times that there had not been sufficient amounts, but this has not been a long standing issue.

The home was mostly kept clean. However, we did note some concerns. We observed multiple pedal bins with missing or faulty lids. This meant rubbish was not well contained, or staff needed to lift the dirty lid with their hands. This risks their hands being unclean after touching the bin lid. We observed multiple staff who were not ‘bare below the elbow’. This is an expected infection control process, to allow good hand hygiene. As staff wore watches, nail polish and bracelets; this risks their hands not being effectively cleaned and can increase the risk of infection transmission. People were left surrounded by old food debris’ for long periods. We observed a toilet brush did not have a container. This exposure risks people touching the contaminated surface. Staff had access to personal protective equipment (like gloves and aprons) around the building. Staff and people also had access to hand soap to allow effective hand washing.

There were policies in place to guide good infection control practices. However, we found these were not always effective at ensuring good cleanliness was maintained. The registered manager completed regular audits on the cleanliness of the home. These audits showed they had identified concerns and made some improvements.

Most people did not raise any concerns with their medicines. However, one person explained that staff sometimes leave them with their pot of dispensed medication and do not watch the person take it. This is poor practice, as the staff member cannot be assured that the person took all their prescribed medicine without any issues.

Staff told us that they had received training on how to manage medicines safely. They were able to describe how medicines should be managed safely. While staff had good knowledge, we saw that medicines were not always managed safely.

People did not always receive medicines as prescribed. One person was prescribed pain relief four times a day, however staff had been giving this pain relief as they felt the person needed it. They had not recorded the reasoning for not following the prescription. This risks the person not having their pain needs met. The registered manager explained they would review this person’s medicine needs and take action to improve the staff administration of pain relief. Some people required medicine at a specific time to help symptoms of their health condition. There was no guidance on what time the medicine was needed for each person. The medicines round was seen to take several hours and staff did not record what time they administered the time specific medicine. This risks the medicine being given at different times each day, and earlier or later than required. Staff did not always have clear guidance on when to administer ‘as required’ medicine. For example, one person was administered a mood-altering medicine for when they developed increased anxiety or agitation. Staff did not have clear guidance on what behaviours the person might demonstrate or what none-medicine techniques could be used first. This risks the person receiving medicines inappropriately. Before our assessment, an external health stakeholder had reviewed medicines at the service. They identified concerns with medicine recording, time specific medicines and ‘as needed’ medicines. They noted on their second visit some improvements had been made. However, during our visit we saw some ongoing concerns. This meant that medicines improvements were not yet embedded at the service. Before the assessment, the NHS auditing team had requested that staff read the medicine policies, then sign that they had read them. We found only one staff member had signed the policy. We were therefore not assured that staff were aware of medicine policies. Medicines were stored in a safely locked room and at a good temperature.