Brookfield residential care home in Gosport is found to be 'not always safe' - and has smelly carpets

And the assessment of people’s capacity to make decisions was not in line with the law at Brookfield Residential Home, Care Quality Commission inspectors discovered.

Brookfield, in Alverstoke, was rated ‘requires improvement’ overall due to safety, effectiveness and whether it was well led.

The report, published this month, highlighted the lack of detail, consistency, accuracy and updates on some risk assessment and management plans. It says out-of-date information was held and changes in people’s needs or their current condition were not recorded.

‘Where someone had lost weight, and their mobility had reduced, their nutritional risk assessment and pressure ulcer risk assessment did not reflect this change,’ the report says.

Regarding the health and safety in the building, inspectors said that they were ‘not safely managed’.

‘A recent fire safety audit by the fire service had highlighted several significant gaps in fire risk assessment and management, including issues with the building and improvements needed in evacuation procedures and carrying out evacuation drills.’

Protocols such as PRN (prescribed as needed medicines) of some people did not contain enough information on their use.

‘Particularly where a person was on several medicines for constipation, or where the dose was variable, staff did not record the reason PRN medicines were given, or if the medicine worked to relieve the symptoms treated.’

The report also indicated that some home areas required maintenance, deep cleaning, and design and decoration adaptation.

‘Some carpets had stains or ingrained dirt and a lingering odour, they required replacement, and there were areas of significant damage to walls, doors and doorframes from equipment.

‘Some doorways were narrow and difficult to fit equipment and people in wheelchairs.

‘The décor was not in line with dementia-friendly guidance, such as highly patterned carpet, lack of individualisation or signage for people’s rooms, or directions to bathrooms.

‘The dining room did not have enough chairs with arms for those who would benefit, and there was a lack of tables available for people in the conservatory to ensure they had access to drinks at all times.

‘Some mattresses were too long for the divan bed frame, mattress protectors were not always appropriate, or were damaged.

‘On the first day of the inspection, officers noted that one of the two shower rooms was out of order and awaiting work to be completed, meaning there was one shower available for 25 people. This was fixed by the second day of the inspection.’

Commission officers were also surprised by the fact that visitors still were asked to undertake a lateral flow test before entry, asked to pre-book visits and remain in a living room away from most people living in the home, meaning that the visiting policy had not been updated even though Covid-19 measures were lifted many months ago.

The registered manager told the officers that the measure was agreed upon with people and their relatives, and accommodations were made for urgent or sensitive visits.

Assessment of people’s capacity to make decisions was also not in line with the Mental Capacity Act 2005 (MCA), which provides a legal framework for making particular decisions for those who may lack the mental capacity to do so for themselves.

‘Some consent forms within care records, such as for photographs to be taken or for sharing of information, were signed by a member of staff on behalf of the resident. However, staff cannot consent on people’s behalf. There was no indication of whether the person had given verbal consent or if they had the capacity to consent.

‘One person had an impairment affecting their mind or brain, which would prompt an assessment of their capacity to make decisions, particularly where these were more complex.

‘People were presumed to have the capacity, however where measures in place were restrictive, there was no evidence people were given the information about options, risks, pros and cons about these measures to enable them to express their view or make the decision.’

Governance and oversight of the home were also under the spotlight since audits were not always highlighting issues identified by external parties, such as fire risks, health and safety within the building, medicines issues and mental capacity assessment.

However, the commission received positive feedback from different parts, such as the advanced nurse practitioner saying that the home was ‘exemplary’ and that they worked productively together.

One relative also said: ‘Communication has been excellent. Internal communication appears very good, with all staff appearing to be very knowledgeable on residents’ situations.’

Relatives said that staff were ‘well mannered, kind, caring, professional’, and another one said, “They have helped [relative] with her dementia and have kept us all as a family up to date. [Relative] is very happy living at the home.’

The register manager said to the Local Democracy Reporting Service that they ‘have worked closely with CQC in rectifying any concerns, the majority of which have been completed, and we are looking forward to getting back to our previous long-standing rating of good.’

Brookfield House was issued with two warning notices by the CQC, on the grounds that ‘the provider did not ensure the premises and equipment was clean, secure, suitable for the purpose it was being used for’ and ‘the provider did not ensure governance and oversight of the running of the service was robust, and records were not maintained to be accurate, up to date and consistent.’