Brewster 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

We identified 2 breaches of the legal regulations. The provider had not always managed risks to people’s safety effectively or acted promptly to learn from safety incidents. People's medicines were not always managed safely. The provider's safeguarding processes were not always effective in protecting people from the risk of harm and abuse. There were enough staff available to provide people with support when required.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Concerns about people's health and safety were not addressed promptly to ensure lessons were learnt. For example, where there had been an increase in the frequency of safety incidents involving people; the provider was not always able to demonstrate what measures they were putting in place to minimise the risk of a reoccurrence. This meant people continued to be at risk of harm.

Staff knew where to record incidents and accidents and told us they had discussed learning when things went wrong. However, staff were not always able to provide specific examples of what they had learnt or what changes had been made as a result. The management team showed us examples of the lessons learnt shared with staff; however, these were generalised and lacked specific details about the improvements needed.

The provider's processes for addressing and learning from safety concerns were not effective. The provider had not always completed detailed investigations or analysed incidents to identify themes. This meant measures were not always put in place promptly to mitigate risks to people's safety.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not always protected from the risk of abuse. During the assessment, we found examples of safeguarding concerns which had not been managed correctly. This meant it was not always clear what immediate actions had been taken or how people had received appropriate support to ensure they were protected. People's relatives told us they had not always been informed or kept updated about safeguarding concerns.

Staff understood how to recognise and report safeguarding concerns. Comments included, "If someone was at risk, I would report it to a manager and if I didn’t feel that was being taken seriously, I would go higher up to the head office" and "I would speak to my line manager first and follow the company policy". However, not all staff we spoke with knew how to access the safeguarding policy or whether there was a safeguarding lead in the service. We received mixed feedback about how confident staff were their concerns would be listened to and responded to promptly. Staff told us changes and instability in the management team had impacted their confidence. Comments included, "I feel they would take it 80% seriously. Our management keep changing, we know the situation more than the management, if we say we have a concern sometimes they won’t listen from our perspective" and "We have had so many people [from management] coming in, there’s no communication, I’m so confused as to who we do and don’t talk to." The management team told us they were currently reviewing how safeguarding concerns had been managed and identifying areas for improvement. A new quality lead for the organisation had been brought into the service to provide additional support with this review.

We observed people receiving safe care from staff during our assessment, with no safeguarding concerns identified.

The provider's safeguarding processes were not robust. Safeguarding notifications had not always been raised where appropriate and this had not been promptly identified by the provider. Investigations had not always taken place and there was a lack of analysis to understand what had happened which placed people at continued risk of potentially avoidable harm. It was not always clear what actions the provider had taken in response to safeguarding concerns. The provider had not ensured all staff had up to date safeguarding training and knew who to report concerns to or where to access safeguarding policy documentation.

Risks to people's safety were not always well managed. Information in people's care plans contained contradictions and inaccurate information. This meant there was a risk staff may not know how to support people safely. Where people were experiencing episodes of distress, staff had not always completed incident reports in sufficient detail to reflect how people were being reassured and how risks to the person and others had been mitigated. This meant it was unclear how the person was being supported safely and sensitively through their distress. We received some mixed feedback from people's relatives about how well safety incidents had been addressed to prevent further risks. Despite this, relatives we spoke with told us they felt people were safe living in the service.

Whilst we found staff did not always have clear, consistent guidance in place to manage risks to people safety, staff we spoke with were able to identify people's individual risks and explain how these were monitored. The management team told us health and safety risks were discussed during staff handovers and at the daily meeting attended by staff and management.

We observed staff supporting people safely. No concerns were identified with the safety of staff practices during our assessment.

The provider's processes for reviewing and managing risks were not robust. Where incidents had taken place which demonstrated repeated risks to people's safety, it was not clear how the provider was analysing this information to ensure appropriate actions were taken. For example, where there had been a significant increase in people having falls from one month to the next, the provider was not able to evidence whether there were any causes for this increase or what specific actions were being taken to mitigate future risk.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us there were enough staff available to provide support. Comments included, "I do feel there is enough staff on duty, sometimes maybe they could do with extra, but they always have time for the residents if need be", "You always see staff walking around" and “I feel there are enough staff around, I always see someone."

Staff told us they felt there were enough staff available to keep people safe; however, we received mixed feedback about whether there was enough time to spend engaging in meaningful conversations or activities with people. The management team told us there was an activities team in place to support people with a range of different opportunities to socialise and engage with others. They confirmed people's dependency needs were reviewed monthly to ensure appropriate staffing levels were in place.

We observed appropriate staffing levels in the service during the assessment. Staff were visible and available to provide people with support when needed.

The provider's processes for recruiting staff were not always robust. Employment checks had not always been completed accurately prior to new staff starting work. For example, we found gaps in applicant's employment histories and references. The provider was not able to demonstrate all staff received regular supervisions. This meant it was unclear how the provider was reviewing staff performance, identifying concerns, or providing support and opportunities for staff to develop. The provider had oversight of staff training and monitored renewal dates to ensure compliance.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People did not always receive their medicines as prescribed. This meant there was a risk medicines were not being administered safely. Where people were prescribed medicines to support them during episodes of distress, we found staff were not following the prescriber's specific instructions for when these medicines should be administered. For example, one person was being supported to take a medicine daily which was only meant to be given during periods of distress. Another person was prescribed medicine to support them during a specific medical intervention; however, we found this was being given more frequently to support them during periods of distress. This meant people were not receiving their medicines as intended by the prescriber and the effect of this overmedicating was not known. This placed people at risk of harm.

Staff were not always able to demonstrate medicines were managed safely. For example, staff we spoke with were not able to evidence whether the amount of a person’s medicine in stock was correct given the amount which had been administered. Staff had not always completed medicines administration records accurately and legibly. This meant it was not always clear what the stock balance should be. We found medicines had not always been administered appropriately, with a lack of information recorded to explain why a particular medicine was required at that time. Following our feedback, the provider confirmed a full medicines audit had been completed by the pharmacist and improvements were being implemented.

The provider's processes for managing medicines were not robust. The provider had not ensured people always received their medicines as prescribed. Medicines documentation had not been monitored effectively to ensure it was being completed accurately. For example, we found instructions for the administration of covert medicines [administered in a disguised form] which contained incorrect information about the person and their medicines. The provider was not able to demonstrate how they monitored the stock of medicines to ensure errors were identified without delay. The provider had not ensured all staff were competent in the completion of medicines documentation.