Our response to the CQC report
1. From reviewing accidents and incident records, as well as medicine management records we identified examples of incidents which had not been reported to the local authority safeguarding team and to CQC, as required, to maintain people's safety and welfare
Management team at Brooke House are always open and transparent and working in line with Norfolk County Council Safeguarding Policy, Local GP and resident families. We would like to reassure all resident families regarding reportable incidents are followed through robustly in line with duty of candour. All incidents, accidents or medication errors are being recorded, investigated, shared with relatives concerned and reported to the relevant agencies where necessary.
2. We identified risks within the care environment, where equipment needed to be replaced, changes were needed to reduce the risk of harm to skin from hot and uncovered surfaces and unsecured access to risk items, which placed people at risk of potential harm. This was of particular concern because many of the people at the service were living with dementia and relied on staff to maintain their safety
We feel that the inspection team were harsh and not proportionate in their approach with the home. We had adequate staffing in place to support and monitor resident safety which is noted in the report.
At the time of inspection, no resident was at risk or nor did we have any who liked to touch hot surfaces. The radiators are not hot to touch .We would like to note that we have not had any incidents of residents coming to harm from hot or uncovered surfaces. We also want to note that all our hot water taps are regulated with TMV Valves which ensures that all water is within regulated temperatures are checked regularly. This minimises the risk that the regulator has stated in the report. All monthly records were reviewed and in place at the time of the inspection which demonstrated no issues. We addressed all the areas highlighted and purchased new equipment within the inspection timeframe
There is a commitment from Kingsley Healthcare to ensure our environments are of high quality and we have large Investment spent and plan going forward. Ovamills are our contractor who is responsible for conducting and completing all our buildings work/refurbishment in excess of 5M. There is an on-going plan to upgrade home environment which includes all the areas highlighted during and prior to CQC Inspection visit which Overmills are currently undertaking
3. We identified some areas of environmental security needing to be improved. This was of particular concern as a person had managed to leave the service without staff being aware in February 2023, and some people living at the service had Deprivation of Liberty Safeguards in place.
Our response to resident absconding incident demonstrated proactive and responsible approach to resident’s safety. Resident came to no harm. By following correct procedures, reporting incident to relevant authorities, and implementing security enhancements we have taken important steps to prevent future absconding incidents and provide secure environment for our residents.
4. We identified risk items unsecured within the service. People living with dementia were at risk of consuming drink thickener being left in communal dining/ lounge areas and we found denture cleaning tablets and other personal care products including prescribed creams unsecured in people's bedrooms.
We would like to note that we have not had any incidents of ingestion or resident consuming drink thickener. We made immediate changes to increase and ensure safety of our residents. Additional storage containers were purchased for secure storage of fluid thickeners. Denture cleaning tablets were placed in the lockable medication trolleys.
5. We identified number of windows without restrictors in place to aid security and reduce the risk of people failing from a height.
We feel that the inspection team were harsh and not proportionate in their approach with the home. We had a window restrictors in place however they were 3cm out of sync. These were on the top window where a resident would need to climb a ledge and would not fit through the gap. Following the inspection we immediately addressed the issue and kept the inspection team updated.
6. Some areas of medicine management needed to be improved to ensure staff were working in line with local and nationally recognised best practice. We identified out of date medicine, and medicine that had been discontinued by the prescriber to still be accessible to staff in the medicine room, increasing the risk of unsafe or accidental use. Where people needed as required 'PRN' medicine, for the management of constipation or anxiety, the PRN protocols for staff to follow lacked sufficient detail. This was of particular concern as some people were unable to easily communicate their needs and wishes
Brooke House is using Atlas, electronic medication management system which assists staff to administer right medicines to the right resident at correct time. Staff using the Atlas system correctly would not allow administration of medicine which is no longer on the list of active medicines therefore there was no risk that discontinued medicine would be given.
PRN protocols are in place just as a guidance to help make a decision if medicines are required – this is especially useful for agency senior staff which we are not using. Our staff will always follow instruction recorded on medicine label and doctors instructions, they are very experienced, knowing residents and their needs very well.
7. We observed some people's teeth and finger nails to be visibly dirty, their daily records indicated gaps in the completion of these basic care tasks
We conducted a review of our record system and have put additional measures in place to ensure that clear records are in place. People now have planned day care set up for brushing teeth and personal grooming. This was an isolated incident concerning one resident.
8. Provider level auditing and oversight of the service, in the absence of a registered manager required some improvements, as areas of risk and shortfalls identified at this inspection had not been found as an outcome of their own audits and quality checks
We previously had managers in the position, but they have departed from their roles for various reasons. In the meantime home is managed by deputy manager who has worked at Brooke House for over 7 years with a support and frequent visits from Operations Manager and a Service Quality Team.
9. Areas of the service were found to be visibly unclean, including a high level of mould in a communal bathroom, and rust evident on equipment impacting on the ability to keep items clean
The home was not unclean nor did it have any odours. We have full complement of housekeeping and domestic staff who take pride in maintaining the cleanliness of the home. Positive feedback has been given during our survey results from people who use the service or visiting with no concerns.
The mould found on the day had been reported to regional asset manager 3 days prior to inspection and relevant action was taken, the bathroom was taken out of use and signage was put in place.
