Brockton Care Limited deteriorated from Good to Requires Improvement, with breaches of Regulations 12 and 17 due to unsafe medicines management, missed/late visits, and ineffective governance failing to ensure staff training and Mental Capacity Act compliance. Despite these failings, the service demonstrated genuine caring values, safe recruitment, effective infection control, and strong partnership working with external agencies.
Concerns (10)
criticalMedication management: “The management of medicines did not ensure people received their medicines as prescribed, placing them at risk of harm. This is a breach of regulation 12.”
criticalMedication management: “Prior to our inspection visit 1 relative had raised concerns that a medicine that had no longer been prescribed, had been administered to their relative.”
criticalConsent / capacity: “One out of 8 members of staff we spoke with was unaware of the Mental Capacity Act, 3 members of staff did not have a clear understanding.”
criticalGovernance: “The provider's governance was ineffective to ensure all staff had access to relevant training or to adapt the principles of the mental capacity act. This is a breach of regulation 17.”
criticalRecord keeping: “Vital information relating to people's prescribed medicines were not contained in their records, placing them at potential risk of harm.”
moderateMissed or late visits: “Five out of 13 people we spoke with told us they had experienced a missed call. One person told us their night call had been missed and they had to go to bed in their day clothes.”
moderateStaff training: “Staff had not received training in these areas. For example, the provider offered a service to a person who had a diagnosis of epilepsy and another person who was receiving end of life care.”
moderateEnd-of-life care: “There was no evidence staff had received end of life training. A senior care staff told us staff watched a DVD on death and bereavement.”
moderateComplaints handling: “The registered manager did not apologise to the complainant and care and support was withdrawn. Hence, the principles of the duty of candour had not been applied.”
minorCommunication with families: “People told us when they telephoned the office about a call being late or missed, swift action was taken. However, no one from the office had contacted them to say the call would be missed.”
Strengths
· People felt safe and staff demonstrated good understanding of safeguarding; all staff had received safeguarding training.
· Staff treated people with kindness, dignity and respect, and people were actively involved in planning their care.
· Effective infection prevention and control measures were in place, with staff wearing PPE and maintaining good hygiene standards.
· Risk assessments were in place and people were involved in managing risks to themselves.
· The provider worked closely with healthcare professionals and external agencies, including use of the SBAR tool to reduce hospital admissions.
Quality-Statement breakdown (25)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood