Brook House run by Stepping stones residential care limited OSV-0005419. Highlights from this inspection of Brook House run by Stepping stones residential care limited the same company that run Lois Bridges.
During the inspection one “resident was had chosen to spend time in their family home” but the family were unclear if the resident was able to return to Brook House. This sound like removed a person while the inspection is taking place? would this be because the family were not happy and expressed their dissatisfaction with the communication pathways, similar to what a resident said “reluctant to raise concerns” The inspection was triggered on receipts of information of concern and 5 areas of non compliance was found including no person in charge and residents and families “unclear and they were unsure who to engage with”
Residents disappointment with communication and staff leaving and expressing a preference to return to their family home. They were reluctant to raise their concerns to the inspector
The provider could self identify issues within the centre, it did not always have the capacity or capability to drive the improvements required. I can see problems but i cant fix problems, very interesting i wonder if money has anything to do with this, considering that admission were being fast tracked without a person in charge or people appropriately trained to meet the assessed needs of residents.
Despite the best efforts of the provider, some documentation was not readily available during the inspection. Oldest trick in the book, we cant find it now, we will post it out later.
What residents told us and what inspectors observed
During the inspection a resident told the inspector that they were relatively happy in the centre. However, they did say they would prefer to return to their family home. Furthermore, the resident said they were disappointed with the way they were informed about the person in charge leaving the centre. A resident also told the inspector that while staff were very nice, they would be reluctant to raise concerns now that the person in charge had left.
Additionally, a resident’s representative noted their dissatisfaction with the current communication pathways within the centre. They felt this was compounded by the lack of an appointed person in charge. For example, during the inspection a resident had chosen to spend time in their family home. The resident’s family noted they were unclear if the resident was able to return to the designated centre. This was raised with the provider during the inspection. The provider clarified with the resident and their representative, that there was appropriate staffing arrangements in the centre to ensure the resident could safely return at any time.
Capacity and capability
This risk based inspection was triggered on receipt of unsolicited information of concern. This inspection identified that the current governance and management arrangements did not demonstrate effective oversight of the centre. This lack of effective oversight negatively impacted the capacity and capability of the centre, which adversely impacted residents lived experiences.
From a review of notifications and discussions with the provider during the inspection, the inspector noted that the former person in charge had left their post. While the provider had recruited a new person in charge, this person had not started their new role. This left the centre without an appointed full time person in charge. The provider had put an interim arrangement in place but this arrangement did not satisfy Regulation 14: Persons in charge. Furthermore, a representative of a resident told the inspector that the current person in charge arrangements were very unclear and they were unsure who to engage with regarding a residents support needs.
The provider had recently restructured the governance and management arrangements of the centre. This included the appointment of a residential co-ordinator, who the new person in charge would report to. Additionally, a team leader was appointed and this person was to report to the new person in charge. The inspector acknowledged that these new arrangements would enhance the overall governance and management of the centre. That being said, they were not fully embedded at the time of inspection and therefore the lines of authority and accountability within the centre were unclear.
The provider had completed an annual review of quality and care within the centre. However, the annual review did not demonstrate how residents or their representatives were consulted. The provider had systems in place to monitor and review the quality of services provided within the centre. However, while these systems identified service deficits, appropriate actions were not always undertaken to address these issues in a timely manner. This showed that while the provider could self identify issues within the centre, it did not always have the capacity or capability to drive the improvements required. Despite the best efforts of the provider, some documentation was not readily available during the inspection. This highlighted the need for the provider to enhance their information management systems.
The provider had ensured that staff training such as safeguarding vulnerable adults, medication management, fire prevention and manual handling were up to date. However staff had not received appropriate training to meet the assessed needs of residents. For instance staff had not received training to enable them to adequately support residents presenting with mental health difficulties. Therefore some staff felt that while they were doing their best to support residents, they didn’t have the formal training to ensure residents were appropriately supported. The admissions process to the centre required significant improvement. Due to the COVID-19 pandemic the provider accelerated the admission of a resident to the centre. A review of documentation and discussions with residents and their representatives found that admission to the centre did not adequately consider the wishes and needs of residents currently living within the centre. It was also unclear if an appropriate compatibility assessment was conducted prior to the admission. A review of this admission by the provider acknowledged that the centres admissions process had not been followed.
Regulation 14: Persons in charge
At the time of inspection there was no active person in charge appointed to the centre.
Judgment: Not compliant
Regulation 16: Training and staff development
Staff had received core training and refresher training. However, appropriate training to support residents with their assessed needs had not been provided. For example, staff had not received appropriate mental health training or suicide prevention training.
Judgment: Not compliant
Regulation 23: Governance and management
There was no active person in charge in the centre and therefore the lines of authority and responsibility were unclear. There was a lack of effective monitoring of the centre. The annual review of quality and care within the centre did not demonstrate consultation with residents or their representatives.
Judgment: Not compliant
There was no evidence that a robust compatibility assessment of a resident was completed prior to new admissions.
Judgment: Not compliant
Regulation 7: Positive behavioural support
There was insufficient guidance available to staff to ensure residents’ assessed needs were proactively supported.
Judgment: Not compliant
Brook House run by Stepping stones residential care limited OSV-0005419. Highlights from this inspection of Brook House run by Stepping stones residential care limited the same company that run Lois Bridges.
Further inspections click here
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