CQC report explained · a residential care home
What the CQC found at Brent Cottage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans had improved, and safeguarding and staffing arrangements were better. However, new staff did not always know the information in people's care records, and staff had not always recorded as-required medicines correctly.
- Effective?
- Requires improvement
- Care plans were more personalised and people had better health support. Staff training and support had improved, but not all staff had suitable learning disability and autism training, and further work was needed around choice and best-interest decisions.
- Caring?
- Requires improvement
- People had positive relationships with staff and were generally treated with kindness. However, people's choices about where to spend time were sometimes restricted, and inspectors saw one interaction that did not respect a person's comfort and dignity.
- Responsive?
- Requires improvement
- People's routines, preferences and communication methods were recorded, and activities and relationships were supported. Longer-term goals needed more focus, and not all staff could understand or use people's preferred signs.
- Well-led?
- Requires improvement
- Leadership, reporting and quality monitoring had improved, and the provider had an improvement plan. The new approach and values still needed to become consistent in everyday practice.
What inspectors found, June 2023
Rated Requires Improvement; care had improved after a previous Inadequate rating, but choice, communication and consistent practice still needed work.
This was an unannounced follow-up inspection after the previous Inadequate rating. Inspectors visited on three dates, spoke with people, a relative, staff and professionals, observed care, and checked care, medicine and management records.
The home had made important improvements. Risk assessments and care plans were clearer. Safeguarding, staffing, medicines, cleanliness and management systems had improved. People had better access to community activities, and staff were described as kind and compassionate.
However, all five areas were still rated Requires Improvement. People could not always choose freely where to spend their time. Some staff did not understand people's communication needs or care plans well enough. Longer-term goals and independence also needed more attention.
The previous rating was Inadequate and the home had been in Special Measures. The provider was no longer breaching regulations, and Special Measures ended after this inspection. The CQC will continue to monitor the home and its improvement plan.
Improved safeguarding
Safeguarding systems and incident reporting had improved. Staff had updated training and knew how to report concerns.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 13.” from the report
Clearer risk and care plans
People's risks and support needs were recorded more clearly, with instructions about how to provide care safely.
“Risk assessments had been fully reviewed and clearly identified risks to people's safety and welfare.” from the report
Improved environment
The home was cleaner and better maintained than at the previous inspection. People could personalise their bedrooms.
“At this inspection, the home was clean, spot checks were in place to monitor cleanliness and maintenance was carried out when needed.” from the report
Community activities
People had more opportunities to go out and take part in activities they enjoyed. Staff accommodated some unplanned trips during the inspection.
“People were now supported to understand and discuss their sexuality, understand their needs and how to communicate their wishes and desires.” from the report
Improved leadership systems
The management team had introduced new quality monitoring and improved internal reporting. People had helped reshape the home's values and approach.
“The provider and registered manager had fully developed a new quality monitoring system which they had put in place.” from the report
People could not always choose freely
needs fixingOne person's behaviour sometimes affected whether other people could use shared areas or take part in activities. Some people retreated to their rooms to avoid conflict.
“People's choices about where they spent their time were at times limited.” from the report
New staff did not always know people's needs
seriousInspectors found that some staff, particularly new staff, did not know the guidance in care records well enough. This had contributed to one person's distress during an incident.
“not all staff, particularly new staff were aware of the contents of those care records.” from the report
Communication was inconsistent
needs fixingCommunication plans and tools were available, but not all staff understood or used people's preferred signs. This caused frustration for one person.
“They had to repeat themselves as staff did not understand certain signs, which was frustrating for them.” from the report
Respect and dignity
needs fixingInspectors saw a sarcastic response and physical contact that made a person visibly uncomfortable. The provider acted immediately after this was raised.
“The person responded with an angry look and was clearly not comfortable with the comments or action.” from the report
Medicine records
seriousRegular medicines were recorded more clearly, but staff did not always record when as-required medicines had been given. The provider acted immediately to correct this.
“Staff did not record when an 'As required' medicine was given on the MAR” from the report
Longer-term goals
needs fixingCare planning covered people's routines and preferences, but it did not yet consistently focus on longer-term aspirations, independence, education, employment or moving on.
“Keyworker meetings were regularly held but required further development to ensure people's longer terms goals and aspirations were central to the support plan.” from the report
- 01How will you make sure every new staff member reads and follows each person's care plan and behaviour support guidance?
- 02What has changed to ensure people can use shared areas and choose activities without being pressured to leave?
- 03How will you check that all staff understand and use each person's preferred communication method, including signs?
- 04How are you recording as-required medicines now, and how is this checked?
- 05What specific plans are in place for each person's longer-term goals, such as education, employment, independence or moving on?
This was an unannounced follow-up inspection that assessed all five key questions after the previous Inadequate inspection and checked infection prevention and control. This explanation was written from the published report of 9 June 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, September 2022
Rated Inadequate and placed in special measures; inspectors found serious safeguarding, staffing, care planning and leadership failures.
This was an unannounced inspection on 15 March, 22 March and 13 April 2022. One inspector and a CQC medicines team member visited. They spoke with one person, two relatives and four staff, observed two other people, and reviewed care, medicines, staffing and management records.
The home supported five people with a learning disability and/or autism. Inspectors found people were often treated kindly and staff knew them well. However, support was not reliably safe, personalised or focused on helping people gain independence and skills.
Inspectors found safeguarding concerns were not always reported, risk assessments and medicines records were incomplete, and staffing did not always match people's assessed needs. Staff training and supervision were not sufficient, and the home lacked effective checks to identify and correct problems.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while effective, caring and responsive were rated Requires Improvement. The home was placed in special measures, with an action plan requested and a reinspection expected within six months.
Staff knew people
Staff understood people and knew the triggers for behaviours that could place people or others in danger.
“Staff knew people well and were knowledgeable about triggers to behaviours which put people and others in danger.” from the report
Kind and respectful care
Inspectors saw staff being warm, respectful and friendly. People and relatives also described staff as kind and caring.
“We observed staff being warm, respectful and friendly towards people.” from the report
Privacy and dignity
Staff respected people's privacy and dignity, including by knocking before entering bedrooms.
“Staff respected people's privacy and dignity. Each person had the privacy of their bedroom and staff were mindful to knock” from the report
Infection arrangements
The home had arrangements for infection testing, visits and managing outbreaks. Its infection prevention and control policy was up to date.
“The service made sure that infection outbreaks could be effectively prevented or managed.” from the report
Safeguarding failures
seriousSafeguarding concerns, including allegations about staff conduct and incidents where people were hurt, were not always reported to the appropriate authorities. Protection plans were not always followed.
“Safeguarding concerns were either not identified or notified to the appropriate organisations. This placed people at risk of harm.” from the report
Risk and medicines records
seriousSome risks, including falls and weight gain, did not have effective plans. Medicines records were unclear and handwritten changes were not properly checked.
“Safety concerns were not consistently identified or addressed. This placed people at risk of harm.” from the report
Staffing and training
seriousRotas did not always provide the one-to-one support people were funded for, and staff were not always aware of safe numbers for community activities. Recruitment checks and refresher training were also incomplete.
“The lack of staff to meet people's needs and unsafe recruitment process was a breach of Regulation 18” from the report
Limited personalised support
seriousCare plans did not set out people's individual goals, communication needs or ways to build independence. Activities were often offered to everyone rather than chosen for each person.
“People were not receiving personalised care and support to meet their needs.” from the report
Weak leadership and checks
seriousThe provider and manager did not have effective systems to monitor quality, learn from incidents or make sure actions were completed. Inspectors described a closed culture.
“The lack of effective leadership, lack of governance systems and processes in place to ensure the safety of the service people received” from the report
Environment and activities
needs fixingBlack mould was found around the bathtub, and people had limited opportunities for activities, new relationships and developing skills.
“Some areas in the home, for example the communal bathroom floor, was scratched and black mould observed around the bathtub.” from the report
- 01What action has been taken to make sure every safeguarding concern is reported promptly to CQC and the local safeguarding authority?
- 02How are you now matching staff numbers to each person's one-to-one support and community risk assessment?
- 03Are all medicines records, including PRN medicines and handwritten changes, now checked and signed correctly?
- 04How are people involved in setting their own goals, communication plans, activities and plans for developing independence?
- 05What evidence can you show that staff have completed current training, supervision and support in autism, learning disability care and positive behaviour support?
This was an unannounced inspection focused on the Right Support, Right Care, Right Culture principles and infection prevention and control, following concerns about safeguarding and personalised support; it assessed all five key questions. This explanation was written from the published report of 2 September 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 Brent Cottage
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2022InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2021Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- June 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
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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