CQC report explained · a residential care home
What the CQC found at Brenalwood Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Rated Requires Improvement; care and management had improved, but medicines, staff training and quality checks still posed risks.
This was an unannounced follow-up inspection on 19 and 27 September 2023. Inspectors observed care, spoke with people, relatives and staff, and reviewed care plans, medicines records, recruitment files and management records.
The home had improved since earlier inspections. There were enough staff for the 15 people living there, agency staff were no longer being used, the building was cleaner and better decorated, and relatives described kind care and better communication.
Important problems remained. Medicines were not always given as prescribed, fire safety checks were not robust enough, staff did not always follow hand hygiene rules, and training and supervision did not always ensure staff could use their learning in practice. Activities and privacy also needed improvement.
All five areas were rated Requires Improvement. The previous overall rating was Inadequate and the home had been in special measures. It improved enough to leave special measures, but the CQC required an action plan and will continue to monitor progress.
Improved staffing
There were enough staff to support the 15 people living in the home, and temporary agency staff were no longer being used.
“Since our last inspection the provider had successfully recruited enough staff and was no longer using temporary agency staff.” from the report
Health support
Staff worked with health professionals and made prompt referrals when people needed medical, dementia, dietetic or speech and language support.
“Prompt referrals were made to health care professionals where needed, including the GP, dementia services, dieticians, and the speech and language therapist (SaLT).” from the report
Improved environment
The building had been redecorated, with new flooring, wash basins and toilets. Cleanliness in areas including the kitchen and laundry had improved.
“There had been significant improvements made to the environment since the previous inspections.” from the report
Positive relationships
Inspectors saw positive relationships between staff and people. Relatives described staff as kind, attentive and gentle.
“We observed positive relationships between staff and people.” from the report
Better involvement
Engagement with people, relatives and staff had improved. Feedback was gathered and used to make changes, including clearer complaints information.
“People's feedback had been gathered and used to make changes.” from the report
Medicines safety
seriousMedicines were not always administered according to pharmacy or manufacturer instructions. Records and plans for as-needed medicines were sometimes incomplete, creating a risk of harm.
“People's medicines were not always being given safely and as prescribed.” from the report
Staff skills and training
seriousStaff did not always show that they understood or used their training. Induction, supervision, appraisal and training for specialist roles needed improvement.
“Staff spoken with struggled to demonstrate how they put leaning into practice.” from the report
Quality checks
seriousAudits had not found the medicines and infection control problems identified by inspectors. Falls at night had also not been properly analysed for patterns or causes.
“A range of audits had been completed, however these had not identified the issues we found with the management of people's medicines, and infection prevention and control.” from the report
Privacy and dignity
needs fixingPersonal information was discussed in a communal area, and staff did not always focus on privacy, dignity, choice and quality of life.
“The manager and staff were observed discussing people's personal details, such as bowel movements with health professionals in the dining room.” from the report
Daily activities
needs fixingAlthough special events had improved, planned activities were not always delivered. Inspectors saw limited meaningful engagement during parts of the inspection.
“Activities plans were not being followed.” from the report
- 01What has changed to make sure every medicine is given in line with pharmacy and manufacturer instructions?
- 02How are staff being tested to show they understand and use their training, including hand hygiene and safeguarding?
- 03What action has been taken on the fire doors, and how are night staff included in fire drills?
- 04How will you make sure planned activities happen every day and are meaningful for each person?
- 05When will a registered manager be appointed, and how will you track the action plan and medicines audits?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also reviewed; it followed earlier inadequate ratings and checked required improvements. This explanation was written from the published report of 2 November 2023 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.
What inspectors found, January 2023
Rated Inadequate and remains in special measures; inspectors found major improvements but some safety and management checks still needed work.
This was an unannounced targeted inspection on 30 November 2022. Two inspectors checked whether the home had met warning notices about safe care and good governance. They observed care, spoke with five staff and reviewed care plans, risk assessments and management records.
The home had improved since the previous inspection in June 2022. There were more staff, less use of agency workers, better cleaning, safer equipment checks, improved training and a more positive staff culture. The kitchen had been refurbished and had regained a 5-star food hygiene rating.
However, some risk information was still missing or inconsistent in care plans and evacuation plans. Audits did not always investigate the reasons behind repeated falls and urinary tract infections. Safe was rated Requires Improvement and Well-led was rated Requires Improvement. The overall rating remained Inadequate because other key question ratings were carried over from the previous inspection.
Cleaner environment
The home had recruited housekeepers, introduced better cleaning schedules and improved infection control. Staff were observed using protective equipment safely.
“Recruitment of housekeepers and enhanced cleaning schedules had improved the cleanliness of the service, minimising the risk of spreading infection.” from the report
Improved staffing
There were more permanent staff, filled night vacancies, dedicated housekeeping and laundry roles, and less reliance on temporary agency workers.
“Recruitment of staff, better management of sickness and reduction in the use of temporary agency staff ensured there were enough staff deployed to meet people's needs and keep the home clean.” from the report
Better leadership culture
Staff described stronger support and direction. Inspectors found a more positive atmosphere and improved morale since the new manager took up post.
“At this inspection we found there was a more positive atmosphere.” from the report
Food safety improvements
The kitchen had been refurbished and cleaned. Food safety management had improved and the home regained a 5-star food hygiene rating.
“Environmental Health had since returned to the service and reaccredited a 5* food hygiene rating, in recognition of the improvements made.” from the report
Training and supervision
Staff had received additional training and were now receiving supervision. The manager also worked alongside staff to check their skills.
“The manager told us they worked alongside staff in a mentoring role and introduced competency-based supervisions to ensure they had the right skills to meet people's needs.” from the report
Incomplete risk information
needs fixingSome care plans and risk assessments did not contain the same information. Evacuation plans also needed more detail about people who might be difficult to wake and about emergency exits.
“However, some information was inconsistent or missing. Additional work was needed to keep care plans under review to ensure information was current and consistent throughout.” from the report
Audits did not find underlying causes
needs fixingManagement checks had improved but did not always explore why falls and urinary tract infections were happening at particular times. Longer-term checks were needed to ensure improvements continued.
“Further analysis as to why there were increased UTI's and falls at these times had not been explored.” from the report
Feedback may not have been impartial
minorPeople were helped by staff to complete a survey. Inspectors said this could affect how freely people gave their views.
“Whilst surveys had been carried out to gain people's feedback, being supported by staff members could hinder the impartiality of people's responses.” from the report
- 01How do you make sure every person's care plan and risk assessment contains complete and consistent information?
- 02How have you updated evacuation plans for people who may be difficult to wake at night?
- 03What have you done to investigate the repeated falls and urinary tract infections identified in the inspection?
- 04How will you check that the improvements in staffing, cleaning and leadership continue over time?
- 05How can residents give feedback privately, without staff helping them complete surveys?
This was a targeted inspection of Safe and Well-led, including infection control; medicines were not inspected and the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 14 January 2023 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 Brenalwood Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2023Inadequatestayed InadequateSafe: Requires improvementWell-led: Requires improvement
- November 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- March 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 21 August 2012.
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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