Working at Brockenhurst

Not enough staff on shifts, leaving residents alone on floors without support for up to 25 minutes.

Some people were observed to be alone on the first and second floors of the service with no staff to support them. Three people with dementia were all showing signs of distress but there were no staff on their floor for approximately 25 minutes.

Major training gaps, with only one carer trained in dementia despite most residents having it.

Training records showed that only one member of care staff had completed dementia training.

No proper oversight or systems from leaders, so risks and incidents are not managed or learned from.

The provider’s internal systems for checking quality were not effective in identifying shortfalls, including in the administration of medicines, poor record keeping and failures in care planning.