CQC report explained · a residential care home
What the CQC found at Brightcare
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People received medicines safely and on time. Risks were assessed and there were enough staff in most circumstances, but fire checks were not always completed as often as required and staffing levels were missed twice during sickness and leave.
- Effective?
- Good
- Staff were trained and supported, and followed the principles of the Mental Capacity Act. People received suitable food, help with their health needs and referrals to health professionals when needed.
- Caring?
- Good
- Staff treated people with dignity and respect. They were patient, listened to people and supported their independence.
- Responsive?
- Good
- Care plans reflected people's routines, wishes and preferences. People had activities and opportunities to go out, although activity records were not always detailed.
- Well-led?
- Good
- The manager was approachable and quality checks were in place. Records were accurate and secure, and earlier problems with monitoring and notifying the Commission had been addressed.
What inspectors found, November 2017
Rated Good; inspectors found safe, kind and personalised care, with some records and staffing checks needing improvement.
This was an unannounced inspection on 12 and 14 September 2017. One inspector reviewed care plans, risk assessments, medicines records, staff files, rotas, training records, maintenance checks and quality records. They spoke with people using the service, staff, the manager, relatives and a social care professional, and observed care.
The inspectors found that people received their medicines safely, had enough staff to meet their needs and were protected by risk assessments and recruitment checks. Staff were kind, patient and respectful. People were involved in decisions, supported to be independent and received care based on their preferences.
The home had improved since the previous inspection in July 2016. The earlier problems with medicines, care planning, premises, complaints, notifications and quality monitoring had been addressed. The inspectors identified some areas for improvement, including the frequency of fire safety checks, staff supervision, staffing levels during some sickness and leave, and recording of activities.
The overall rating was Good. Each of the five areas was also rated Good: Safe, Effective, Caring, Responsive and Well-led.
Safe medicines
Medicines were administered safely and at the correct time. Staff were trained and their competence was checked.
“People received their medicines when they should and safely.” from the report
Kind and respectful staff
Staff listened carefully, understood people's communication and treated them with dignity. People appeared relaxed and happy with staff.
“People were treated with dignity, respect and staff adopted a kind, calm, and caring approach.” from the report
Personalised care
Care plans included people's preferred routines, abilities and support needs. People were involved in planning and reviewing their care where possible.
“People received personalised care and support and their care plans reflected their preferred routines.” from the report
Improvement since the last inspection
The provider had addressed the earlier problems involving medicines, care planning, the premises, complaints, notifications and quality monitoring.
“At this inspection, the provider had addressed these shortfalls.” from the report
Staffing during absences
needs fixingThe planned staffing levels were not met twice in September 2017 because of sickness and leave. The arrangements for covering these gaps had not been entirely successful.
“these staffing levels had not been met twice in September 2017” from the report
Staff supervision
needs fixingStaff supervision was not always carried out as often as the provider required. The inspectors identified this as an area for improvement.
“Supervision however was not carried out in line with the provider's required frequency” from the report
Activity records
minorPeople had activities and choices, but records did not always clearly describe what people had done.
“these were not always well detailed in records and this is an area we have identified for improvement” from the report
- 01How do you now make sure all fire safety checks are completed at the required frequency?
- 02How do you cover shifts when staff are off sick or on leave, and what staffing levels are in place today?
- 03How often do staff receive supervision, and how do you check that this happens on time?
- 04How are activities planned around each person's choices, and how are they recorded?
- 05What checks show that the improvements made after the July 2016 inspection have been maintained?
This was an unannounced comprehensive inspection covering all five questions and the overall rating. This explanation was written from the published report of 11 November 2017 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 2016
Rated Requires Improvement; inspectors found kind, effective care but concerns about medicines, maintenance, personal goals and oversight.
This was an unannounced inspection on 7 and 8 July 2016. Inspectors spoke with all four people living at the home, three staff and the registered manager. They reviewed care plans, medicines, staffing, training, complaints, maintenance and quality checks, and observed people who could not communicate verbally.
People said they were happy, safe and comfortable, and liked the staff. Inspectors found kind and respectful care, enough staff, personalised care records, health support and suitable training. However, medicines were not always stored or recorded safely, and some repairs and replacements had not been completed.
Inspectors also found that people's goals were not always followed through, the complaints procedure could not be found, some legal notifications had not been sent, and quality checks had missed problems. The overall rating was Requires Improvement. Effective and Caring were rated Good, while Safe, Responsive and Well-led were rated Requires Improvement.
Kind and respectful staff
People said staff were kind, and inspectors saw respectful, unhurried support. Staff understood people's individual communication needs and encouraged independence.
“We observed many examples of positive interactions between staff and people, with staff showing respect and kindness towards the people they were supporting.” from the report
Personalised care
Care plans included people's routines, communication, health needs and preferred support. Staff knew people well and used this information in practice.
“Each person had a detailed pen picture. This included the most important things about them, the most important things to them and the most important areas where they required support.” from the report
Health support
People were supported to attend routine and specialist appointments. Health action plans and specialist equipment were in place where needed.
“People's healthcare needs had been addressed by the service. They had regular appointments with opticians, dentists and chiropodists and each person had an individual Healthcare Action Plan.” from the report
Enough staff
Inspectors found staffing levels were sufficient during the inspection. Staff had time to support activities, appointments and one-to-one interaction.
“There were enough staff in place to meet people's needs; and requests for assistance were anticipated and met promptly during the inspection.” from the report
Medicine storage and records
seriousThe temporary medicine storage area was not temperature monitored. Records for returning or disposing of some medicines were incomplete.
“Medicines were not stored appropriately or recorded as disposed of safely.” from the report
Repairs and equipment
seriousKnown problems had not always been given a completion date. These included fire doors, damaged kitchen cupboards, an unsafe shed, a bath chair and flooring affecting hoist use.
“Maintenance arrangements had not ensured identified concerns were suitably addressed.” from the report
People's goals
needs fixingReviews did not always set clear goals, assess progress or explain the actions needed to support people's ambitions and new activities.
“Reviews completed did not evaluate existing goals where set and did not map actions needed to meet future goals.” from the report
Quality oversight
needs fixingChecks identified some maintenance problems but did not ensure they were completed. Medicine audits also missed problems with records.
“Therefore, systems had not ensured continuous and effective oversight of all aspects of the service.” from the report
Missed legal notifications
seriousThe home had not notified CQC about two decisions relating to Deprivation of Liberty Safeguards, as required.
“Statutory notifications informing us about two decisions had not been made to the Commission.” from the report
- 01What action has been completed to make sure medicines are stored at the correct temperature and all returned or disposed medicines are fully recorded?
- 02Have the fire doors, kitchen cupboards, bath chair, shed and bedroom flooring problems been repaired or replaced, and what dates were these actions completed?
- 03How are each person's goals and ambitions now recorded, reviewed and progressed?
- 04Where can residents and visitors find the accessible complaints procedure?
- 05What changes have been made to quality checks and legal notifications since this inspection?
This was an unannounced inspection that considered all five key questions and reviewed care, medicines, staffing, training, complaints, maintenance and quality monitoring. This explanation was written from the published report of 15 September 2016 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 Brightcare
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- November 2017Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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