Brook Lodge Care Home

“This inspection was carried out in response to risks identified in relation to staffing and risk management. During the inspection, we identified 2 breaches of regulation relating to people’s safe care and treatment and governance arrangements.”

“Medicines were not always managed safely. This included the administration of ‘as required’ (PRN) medicines prescribed to support people during periods of distress. Systems used to document incidents where people experienced distressed reactions were disorganised, with both paper-based and electronic records in use, which did not always align. As a result, we were not assured this information could be used effectively to understand what people living with dementia may have been trying to communicate, or to identify patterns and implement proactive strategies to reduce and prevent distress.”

“The provider had recently taken action to ensure gaps in the rota were consistently covered; however, feedback regarding staffing levels remained mixed. Observations carried out during the inspection did not identify concerns about staffing levels. However, staff told us there were occasions when a high number of temporary staff were used, which impacted continuity of care, as these staff did not always know people well.”

“Risks to people’s care and support had been assessed; however, further work was required to ensure that when people’s needs changed, all sections of their care plans were reviewed and updated accordingly. People at high risk of poor skin integrity were not always repositioned in line with their risk assessments, which increased the risk of further skin deterioration.”

“Governance processes were not robust, and audits and monitoring systems had not identified all the issues we found during the assessment.”

“Staff feedback about their roles was also mixed; some staff told us they enjoyed their work, while others expressed concerns about their roles and the frequency and consistency of supervision and support.”

“Further work was needed to ensure staff had a good understanding of the Mental Capacity Act. Systems and checks were in place to support safe recruitment. People’s needs were assessed prior to admission.”

“Staff were observed to treat people with kindness and compassion during our visits.”

“The service was receiving support from the local authority and healthcare partners to improve people’s quality of life and safety.”

“We have asked the provider for an action plan in response to the concerns found at this assessment.”

“ ”