CQC report explained · a residential care home
What the CQC found at Briarcroft Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found fire safety risks, poor repairs, dirt and damaged or poorly maintained equipment. They also found gaps in repositioning records, incomplete risk assessments and staff without all the training needed for people's specific needs.
- Effective?
- Good
- This key question was not inspected at this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected at this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected at this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management checks had failed to identify the safety, maintenance and care-record problems. There was no formal provider oversight plan in place at the time of the inspection.
What inspectors found, May 2023
Briarcroft Care Home is rated Requires Improvement; inspectors found safety and management problems despite kind care and some well-managed risks.
One inspector carried out an unannounced visit on 16 March 2023. They spoke with people, staff, a relative and health professionals. They observed care and reviewed care plans, medicines records, staff files, safety records and management records.
The main concerns were fire safety, poor repairs, dirt and poorly maintained equipment. Records did not always show that care was delivered as planned. Some risk assessments and training were missing or incomplete. The inspectors said people had not been harmed, but there was a potential risk of harm.
There were also positive findings. Staff were recruited safely, staffing levels met people's needs, medicines were managed safely, and safeguarding systems were working. Staff were described as kind, open and skilled at supporting people with distress and complex behaviours.
The overall rating changed from Good at the last inspection in 2018 to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three key questions were not inspected at this visit, so their earlier ratings were used in the overall rating.
Staffing and recruitment
The home had enough staff to meet people's needs and completed key checks before staff started work.
“Staff were recruited safely, and there were enough staff to meet people's needs.” from the report
Medicines
Inspectors found medicines systems were well managed, with regular checks and clear information for medicines given when needed.
“People received their medicines safely.” from the report
Support with distress
Staff worked with health professionals and used effective strategies to support people whose previous placements had failed.
“Other individual risks were very well managed. For example, staff were skilled at managing risks around people's behaviours.” from the report
Kind and open culture
Relatives and professionals gave positive feedback about staff. Inspectors saw positive interactions and found the culture open and inclusive.
“The culture of the service was open and inclusive.” from the report
Fire safety and building condition
seriousSome fire risks had not been identified, including locked exit routes and combustible items in an exit route. Parts of the building and some equipment were dirty, damaged or in poor repair.
“Some risks relating to fire safety had not been identified.” from the report
Care records and staff training
seriousRecords did not always show that care was provided as planned. One person's records showed gaps of up to 15 hours between repositioning, and staff lacked up-to-date training about swallowing problems.
“One person was cared for in bed and required assistance to re-position every four hours.” from the report
Weak management checks
seriousRoutine audits and provider checks failed to identify the risks and maintenance problems found by inspectors. There was no formal service improvement plan at the time.
“Governance systems had failed to identify the concerns identified at this inspection.” from the report
Incomplete risk assessments
needs fixingRisk assessments had not always been completed to show why it was safe for people to use bed rails.
“Risk assessments had not always been completed to evidence decision making around whether it was safe for people to use bed rails.” from the report
- 01Have all seven fire service recommendations been completed, and can we see the updated fire risk assessment?
- 02What has been done to repair and clean the shower room, flooring, furniture and equipment?
- 03How do you now check that repositioning and other planned care are recorded at the correct times?
- 04Have all staff completed training on swallowing problems and other needs specific to the people they support?
- 05What formal service improvement plan and audits are now in place to prevent these problems being missed again?
This was an unannounced inspection focused on Safe and Well-led; the other three key-question ratings were not inspected and earlier ratings were carried over into the overall rating. This explanation was written from the published report of 6 May 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, February 2022
Briarcroft Care Home was inspected but not rated; inspectors found good infection control and visiting arrangements.
This was an announced, targeted inspection on 19 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements, and whether COVID-19 staffing pressures affected care.
Inspectors found good practice. Staff had infection control training and used PPE. The home had cleaning checklists, extra cleaning of touch points, testing arrangements, and records of staff vaccinations.
The home followed government visiting guidance. Families could use a conservatory, and relatives also described good use of video calls, phone calls, newsletters and a Facebook page when visits were restricted.
The home was not given an overall rating. Safe was inspected but not rated, so this report does not provide a full judgement on the quality of care across all five areas.
Infection control training
Staff received ongoing training and were seen wearing PPE. The home also kept guidance available for staff to use.
“Staff had ongoing training in infection control and effective use of personal protective equipment (PPE).” from the report
Cleaning arrangements
The home used clear cleaning checklists and gave extra attention to frequently touched surfaces. Communal furniture had also been changed to make cleaning easier.
“There were clear guidelines and checklists to ensure cleaning was completed to a high standard.” from the report
Family visiting
The home followed visiting guidance and provided a conservatory for family visits. Relatives also described alternative contact when face-to-face visits were not possible.
“They have done their best to keep people safe and balance the need for them to see us.” from the report
Testing arrangements
There was a testing process for people living in the home, staff and visitors. The home also kept vaccination records for staff and checked visiting professionals.
“The service had developed a good testing regime for people, staff and visitors.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you keep your infection prevention and control policy and guidance up to date?
- 02How are PPE, testing and vaccination checks managed for staff and visiting professionals?
- 03How are family visits arranged now, including visits in the conservatory and contact by video or phone?
- 04What staffing pressures are there currently, and what measures are in place to prevent them affecting care?
- 05How often are communal areas and frequently touched surfaces cleaned, and how are the checks recorded?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 3 February 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 Briarcroft Care Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2017Requires improvementstayed Requires improvementWell-led: Requires improvement
- October 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Registered with the Care Quality Commission on 8 April 2015.
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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