CQC report explained · a residential care home
What the CQC found at Braydeston Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Individual risks were not always identified, recorded, reviewed or reduced. Inspectors also found medicines management problems and could not be fully assured that staffing, particularly at night, was enough to keep people safe.
- Effective?
- Requires improvement
- The home did not consistently follow the Mental Capacity Act or meet conditions attached to DoLS authorisations. Staff training and supervision were incomplete, and people’s needs were not always assessed in line with best practice.
- Caring?
- Good
- Staff were seen giving patient, kind and respectful care. People were offered choice, privacy and support to remain independent.
- Responsive?
- Requires improvement
- Care plans did not contain enough personalised information and were not consistently reviewed. There were also gaps in end-of-life and communication planning, although activities and contact with relatives were available.
- Well-led?
- Requires improvement
- The provider’s audits identified concerns but did not lead to timely improvements. Management changes and weak records affected the service, although an action plan was in place.
What inspectors found, November 2022
Braydeston Court was rated Requires Improvement; inspectors found kind care and good infection control, but serious gaps in risk, medicines, care records and staff support.
This was an unannounced inspection. Inspectors visited on 26 October 2022 and completed further inspection work up to 9 November. They observed care, spoke with people, relatives, staff and other professionals, and checked care plans, medicines, staffing and management records.
The home was not always safe. Risks were not consistently assessed or managed, medicines records and procedures were not always reliable, and inspectors could not be sure there were enough staff at night for an emergency. Care plans were incomplete or out of date, and staff training and supervision were not consistent.
Inspectors saw permanent staff giving patient, respectful and compassionate care. People’s food and healthcare needs were generally met, activities were available, visiting followed guidance, and the home was clean. However, the systems for gaining consent, involving people in care planning and improving the service were not reliable enough.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were also rated Requires Improvement, while Caring was rated Good. The home had been rated Requires Improvement at the previous inspection and had held this rating for four consecutive inspections.
Kind and respectful care
Inspectors saw staff treating people with patience, compassion and respect. Staff offered choices and encouraged people’s privacy and independence.
“We saw that staff made time for people and interacted in a patient and kind way.” from the report
Food and activities
People’s nutritional needs were generally met, with choices of food and drink. People were encouraged to take part in activities and religious services.
“People's nutritional needs were met and there were activities available.” from the report
Healthcare support
People received the healthcare they needed, and relatives said the home was good at seeking advice and keeping them informed about health.
“People received the healthcare they required, and relatives told us the service was good at seeking advice and attention from professionals.” from the report
Clean environment and infection control
Inspectors were assured that infection prevention systems, visiting arrangements and PPE use were generally effective. The premises and equipment were clean, apart from some issues requiring attention.
“We were assured that the provider was using PPE effectively and safely.” from the report
Environmental improvements
The provider had improved the building with redecoration, new furniture and fixtures, and a café. Further changes were planned.
“These included the opening of a café, redecoration and new furniture and fittings.” from the report
Risks and medicines
seriousRisks linked to conditions including diabetes, epilepsy, dementia and mental health had not always been assessed or managed. Medicines records and procedures were unclear or incomplete, including for controlled drugs and medicines given when needed.
“The individual risks to people had not been robustly or consistently identified, recorded, reviewed or mitigated.” from the report
Incomplete care plans
seriousCare plans did not give staff enough current, personalised information about people’s needs, goals, communication or end-of-life wishes. This created particular risks when agency or new staff were working.
“Care plans had failed to consider specific issues that are common in older people which could result in poor outcomes for them if not addressed.” from the report
Staffing and night-time safety
seriousThere were mixed views about staffing. Some staff said there were not enough people to meet emotional needs, and inspectors were concerned that three night staff might not be enough during an emergency such as a fire.
“We had concerns that the risk to people in the event of an emergency at night, such as a fire, had not been properly assessed.” from the report
Slow improvement and communication
needs fixingAudits found the problems but improvements had not happened quickly enough. Communication with people, relatives and staff was inconsistent, including confusion about visiting arrangements.
“Whilst the quality assurance system in place had been effective at identifying the concerns found on this inspection, it had failed to drive timely improvements.” from the report
- 01What changes have been made to risk assessments and care plans for diabetes, epilepsy, dementia, falls, skin care and end-of-life care?
- 02How are medicines given when needed, creams, patches and controlled drugs now recorded and checked?
- 03How do you make sure capacity assessments, best-interest decisions and DoLS conditions are completed and followed?
- 04How many staff are scheduled at night, and how would you safely evacuate people during a fire or other emergency?
- 05Which staff training and supervision gaps have been completed since the inspection, and how is this now monitored?
This was an unannounced full inspection covering all five key questions, including infection prevention and control; inspectors visited on 26 October and completed remote inspection activity until 9 November 2022. This explanation was written from the published report of 25 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Braydeston Court
5 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- November 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- August 2016Requires improvementup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2016InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- December 2021
Registered with the Care Quality Commission on 6 December 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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