CQC report explained · a residential care home
What the CQC found at Brewster House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2022
Brewster House is rated Requires Improvement; improvements ended its Inadequate rating and Special Measures status, but safety and leadership systems were not yet reliable.
Inspectors carried out an unannounced focused inspection on 30 March 2022. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home had improved since its previous inspection. There were enough staff, medicines were given as prescribed, safeguarding processes had improved, and people received more person-centred support. Staff and relatives described a more positive culture under new management.
However, risk assessments and accident records were not always accurate or complete. Some recruitment checks were not fully documented. The systems for checking quality and safety had improved but were not yet fully established.
The overall rating is Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home was no longer in breach of regulations and was no longer in Special Measures. The other three question ratings were carried forward from the previous inspection because they were not inspected this time.
Enough staff
Inspectors found enough staff to support people well. Staff deployment had been changed so people could receive more consistent support.
“At this inspection there were enough staff available to support people well.” from the report
Medicines
People received their medicines as prescribed. Staff had training and competency checks, and care plans included information about medicines and possible side effects.
“People received their medicines as prescribed. Staff had completed medicines training and understood how to support people safely.” from the report
Improved culture
Staff and relatives described a much more open and positive culture. People were supported with personalised interests and staff had more time to spend with them.
“The culture of the service had significantly improved under the new registered manager.” from the report
Working with health professionals
The home had positive working relationships with healthcare professionals. Referrals were made when people's needs changed.
“The provider had promoted positive working relationships with other healthcare professionals in order to meet people's needs and support staff knowledge.” from the report
Risk records
seriousRisk assessments did not always match people's actual needs. Inspectors found that actions to reduce risks were not always recorded or followed through.
“people's risk assessments did not always accurately reflect people's support needs.” from the report
Accident reporting
seriousSome accident and incident records were inaccurate, and managers were not always told about incidents. This meant lessons and steps to prevent repeat harm were not always clear.
“incident and accident forms had not always been completed accurately and the registered manager had not always been informed.” from the report
Systems not fully established
needs fixingManagement checks had improved but had not yet become reliable or consistent. More time was needed to show that improvements would continue.
“these improvements were not fully embedded into the service and more time was needed for the service to demonstrate sustained improvement.” from the report
Recruitment records
needs fixingThe provider completed recruitment checks, but some gaps in applicants' employment histories were not fully documented. A new process was being introduced.
“However, some gaps were still identified in applicant's employment histories.” from the report
- 01How are falls, accidents and incidents recorded now, and how do you make sure managers are told promptly?
- 02How do you check that each person's risk assessment matches their current needs?
- 03What evidence can you show that the improvements in safety and leadership have been sustained since this inspection?
- 04How are gaps in new staff members' employment histories checked and documented?
- 05What were the ratings for Caring, Effective and Responsive at the previous inspection?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 25 May 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.
What inspectors found, August 2021
Rated Inadequate and placed in special measures; inspectors found serious risks involving safety, staffing, safeguarding and management.
This was an unannounced focused inspection on 23 June and 7 July 2021. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care records, medicines records, staff files and management records.
Inspectors found people were at risk of harm. Records did not always explain people's risks or the care they needed. Staffing and staff deployment did not meet people's needs. Inspectors also found poor support with food, fluids, pressure care, end of life care and personal care.
The home did not respond properly to some safeguarding concerns. Its checks on safety and care quality were not effective. Staff described bullying and feeling unable to raise concerns. The home did follow COVID-19 infection control measures and worked with health professionals, but these strengths did not outweigh the serious shortfalls.
The overall rating fell from Good at the previous inspection to Inadequate. The home is in special measures, which means CQC will keep it under review and normally re-inspect within six months to check for significant improvement.
COVID-19 controls
Staff were using the correct protective equipment and regular testing was taking place in line with government guidance.
“Staff were observed wearing the correct personal protective equipment (PPE) and the provider ensured regular testing was completed in line with government guidance.” from the report
Working with health professionals
The home worked with visiting health professionals, who said staff listened to their feedback and were helpful.
“We have a full handover at the end of every visit, the staff are always willing and helpful.” from the report
Some medicines arrangements
Care plans included people's preferences for medicines, and protocols were in place for medicines given when needed.
“People's care plans contained information about how they liked to be supported with their medicines and protocols were in place for as and when needed medicines such as pain relief.” from the report
People at risk of harm
seriousRisk assessments and care records were incomplete or out of date. Inspectors could not be sure that people received enough food and fluids or the pressure and end of life care they needed.
“People were not protected from the risk of harm.” from the report
Not enough staff
seriousInspectors found that staffing levels and deployment did not meet people's needs. Some people were left without support, including help with repositioning and continence care.
“People are still in bed at 11am due to staff shortages.” from the report
Safeguarding failures
seriousThe home did not always take prompt action to reduce risks during safeguarding investigations or keep the local authority and CQC updated.
“The provider had not taken appropriate action to ensure risks to people were mitigated during safeguarding investigations into allegations of abuse.” from the report
Poor hygiene and personal care
seriousSome people had soiled fingernails, unclean clothing or unclean bedding. Some floors were stained and sticky underfoot, creating risks of infection and illness.
“Some people who were living with dementia, were observed to have faeces under their fingernails” from the report
Weak management checks
seriousThe provider's systems did not identify important problems found by inspectors. Concerns raised during the inspection and by the local authority had not been put right promptly.
“The provider's systems for monitoring the safety and quality of the service were not effective and had not identified the concerns we found at inspection.” from the report
Poor staff culture
needs fixingStaff said they felt bullied and unsupported. Inspectors found that people's care was not consistently person-centred and that many people were left alone for long periods.
“Staff spoke of feeling bullied and unable to talk to managers about their concerns.” from the report
- 01How many suitably trained staff are now on each shift, and how do you check that staffing meets each person's needs?
- 02What has changed to make sure safeguarding concerns are acted on promptly and reported to CQC and the local authority on time?
- 03How are you now checking food and fluid intake, weights, repositioning, pressure care and end of life care?
- 04How do you make sure care plans and risk assessments are complete, current and followed by staff?
- 05What action has been taken about the staff culture, bullying concerns and staff support?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 3 August 2021 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 Brewster House
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- May 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- May 2018Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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