What the CQC found at Bromson Hill Care Home

People inspectors spoke with said they were happy with their care and felt safe. Staff knew how to report safeguarding concerns and escalate them.

“Staff were aware of how to raise concerns with the manager and if needed, information was readily accessible about how to escalate those concerns to external agencies.” from the report

Medicine patches were recorded on body charts, and medicines disguised in food or drinks were handled more safely than at the previous inspection.

“At this visit we found improved practices around medicines disguised in food and fluids and patch medicines were now recorded on body charts to show staff where the patch had been administered.” from the report

The home had reduced its use of agency care staff and staff said greater consistency had improved people's experience.

“At this inspection there continued to be enough staff to provide the care and support people required and the provider's recruitment campaign meant the use of agency care staff had significantly reduced in the home” from the report

The new manager had introduced regular reviews involving health professionals, helping identify changes in people's needs.

“The new manager had introduced regular multi-disciplinary ward rounds in the home involving the GP and frailty nurse to ensure people received regular reviews of their health conditions.” from the report

Some risk assessments were not updated after incidents. A newly admitted person did not have basic care plans for their immediate and significant risks.

“Care plans that had been completed to a 'new standard' continued to fall short of requirements.” from the report

Some medicine patches were not used according to the manufacturer's instructions. Some medicine charts lacked the required second signature, seizure medicine protocols were missing and staff competency checks had not been completed.

“These were not in place and meant we were not assured that these medicines would always be given at the correct time.” from the report

Food and fluid records had gaps, some drinks were left out of reach and there was not enough evidence that people at risk of weight loss received the right support.

“We could not be confident that people who required support, assistance and encouragement to maintain good hydration and nourishment, received effective support.” from the report

Some fire doors were not properly checked or did not close correctly. Window restrictors were not fixed with the required tamper-proof fittings, and further work to the building was still needed.

“We found some fire doors identified as to be closed, were not and some fire doors failed to close properly.” from the report

Audits sometimes recorded that checks were complete without finding problems. The provider had not shown that it had learned from repeated concerns, and this remained a breach.

“The provider has failed to make and sustain improvements to the service and comply with regulations.” from the report

Records did not always show what people had eaten or drunk, and weight-loss records said people had been referred to a GP without evidence that referrals had been made.

“We saw incomplete records of what people had consumed and records that showed people did not have drinks from early evening until the next morning.” from the report