CQC report explained · a residential care home
What the CQC found at Brookholme Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from avoidable harm. There were enough staff, risks were assessed, medicines were managed safely and safeguarding concerns were acted on.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Managers' quality checks were not always effective. Cleaning, repairs and equipment checks were not consistently completed or followed up.
What inspectors found, June 2022
Rated Good overall; inspectors found safe, kind care, but the home needed better cleaning and quality checks.
This was an unannounced inspection on 9 May 2022. Inspectors visited the home, spoke with people, staff and relatives, observed care, and checked care, medicine, recruitment and management records. The inspection was prompted partly by concerns about safety and risks.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, suitable risk assessments, well-managed medicines and appropriate action when safeguarding concerns or incidents arose. Staff had training, including refresher training after concerns about moving and handling.
The home was rated Requires Improvement for Well-led. Quality checks did not always identify problems or make sure they were fixed. Inspectors found areas that were not cleaned to a high standard, incomplete cleaning schedules, some damaged fixtures and stained mattresses or pressure cushions.
The overall rating stayed Good, the same as at the previous inspection published in 2018. However, the Well-led rating fell from Good to Requires Improvement. The other three question ratings were not inspected and were carried over from the previous inspection.
Safe staffing
Inspectors found enough staff to meet people's needs. Recruitment checks and staff training were also in place.
“There were enough staff to support people's needs.” from the report
Safe medicines
Medicines were given as prescribed. Staff had the required training and records were completed correctly.
“People received their medicines as prescribed and medicines were managed effectively to reduce the risks associated with them.” from the report
Safeguarding and risk management
Risks such as falls and sore skin were assessed and managed. Safeguarding concerns were reported and action was taken.
“When safeguarding concerns were identified, action was taken to protect people from further harm and incidents were reported to the local authority safeguarding team and to us.” from the report
Kind and person-centred care
Relatives praised staff's kindness and attitude. Inspectors saw people being supported to spend their day as they wished.
“All the relatives we spoke with complimented the staff on their kindness and attitude.” from the report
Communication and partnership working
The home communicated with relatives and worked with health and social care professionals. Advice from professionals was included in care plans and shared with staff.
“The registered manager and provider engaged and worked in partnership with other health and social care professionals.” from the report
Weak quality checks
needs fixingThe home's audits did not always identify problems or make sure recommendations were acted on. This led to inconsistent management and a Requires Improvement rating for Well-led.
“Quality assurance systems including audits had not always been effective in identifying areas for improvement and driving quality.” from the report
Repairs and equipment checks
needs fixingSome curtain rails were broken and some areas needed repair. There was no regular audit of mattresses and pressure cushions, and some needed replacing.
“There was no regular audit for mattresses and pressure cushions. We identified some of these required replacing due to staining or strike through of the covers.” from the report
Agency staff direction
needs fixingInspectors saw an agency worker who was not sure how to support or guide people. A consultant's recommendation about directing agency staff had not been acted on.
“We observed an agency worker with a lack of direction in the communal space, unsure how to support or guide people.” from the report
- 01What cleaning problems found in the inspection have now been fixed, and how are completed cleaning checks recorded?
- 02How often are mattresses and pressure cushions checked, and have the stained items identified by inspectors been replaced?
- 03Which broken curtain rails and other repairs were completed, and who is now responsible for checking them?
- 04How do you make sure agency staff receive clear direction about supporting people in communal areas?
- 05What changes have been made to the quality audits since the inspection, and how do managers check that recommendations are completed?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were not inspected and were carried over from 2018. This explanation was written from the published report of 24 June 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, December 2020
Inspected but not rated; inspectors were assured that infection prevention and control arrangements were safe during the COVID-19 outbreak.
This was an unannounced, targeted inspection on 09 December 2020. Inspectors checked infection prevention and control arrangements because the home had a coronavirus outbreak.
Inspectors were assured that the home was using PPE safely, following shielding and social distancing rules, managing visitors, accessing testing, and keeping its infection control policy up to date. They also found the home was clean and that people who tested positive were cared for in a separate part of the home.
The home was inspected but not rated. This report therefore gives findings about infection prevention and control only, rather than a full quality rating.
PPE and infection training
Staff had training in using PPE and COVID-19 infection control. PPE was accessible and staff used it in line with current guidance.
“Staff had received training in donning and doffing personal protective equipment (PPE), and we saw this was accessible throughout the home and staff used it in accordance with the most up to date guidance.” from the report
Cleanliness
Inspectors found the home clean, with extra cleaning and regular wiping of touch points.
“The home was clean throughout and additional cleaners had been utilised to ensure that the home was consistently clean and touch points regularly wiped.” from the report
Managing the outbreak
People who tested positive were kept in a separate part of the home, with a dedicated staff team to reduce the risk of cross-contamination.
“The home keep those people who had tested positive in a separate part of the home.” from the report
Updated procedures
The infection control policy was kept up to date. The home also developed a standard operating system covering outbreaks and people's and staff wellbeing.
“A new standard operating system had been developed during the pandemic.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your infection prevention and control arrangements changed since the inspection on 09 December 2020?
- 02What visitor arrangements are currently in place, including for people receiving end-of-life care?
- 03How do you keep people who test positive separate from others, and how is cross-contamination prevented?
- 04How do you support residents' wellbeing when visitors cannot enter the home?
- 05How often are PPE supplies, cleaning arrangements and infection control policies reviewed?
This was an unannounced, targeted inspection of infection prevention and control during a coronavirus outbreak; it was inspected but not rated and did not assess the other four questions. This explanation was written from the published report of 30 December 2020 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 Brookholme Care Home
2 rated inspections over 4 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- July 2018GoodSafe: GoodWell-led: Good
- April 2017
Registered with the Care Quality Commission on 5 April 2017.
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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