CQC report explained · a nursing home
What the CQC found at Brookholme Croft Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe, and there were enough staff to meet their needs. Risk assessments, recruitment checks, medicines systems and accident reviews were in place.
- Effective?
- Good
- People's needs were assessed and care plans were updated as staff learned more about them. Staff had a mixture of online and face-to-face training, and worked with healthcare professionals.
- Caring?
- Good
- Inspectors saw caring interactions and found that staff treated people with kindness, dignity and respect. People and relatives were involved in care planning and people could choose their daily routines.
- Responsive?
- Good
- Care was personalised around people's histories, preferences and communication needs. The home offered activities and trips, responded to complaints and provided end of life care.
- Well-led?
- Good
- The manager was described as approachable, and people, relatives and staff were involved in decisions about the home. Audits, action plans, meetings and feedback systems were used to monitor and improve care.
What inspectors found, February 2020
Rated Good; inspectors found safe, kind and personalised care across all five areas.
This was an unannounced inspection on 30 December 2019. One inspector spoke with six people living at the home, three relatives and a visiting healthcare professional. They also observed care and checked records about staffing, medicines, accidents, incidents and quality checks.
The inspectors found enough trained staff, safe medicines systems and good infection control. People said they felt safe, staff were kind and caring, meals were good, and activities and trips were available. Staff worked with healthcare professionals to meet people's needs.
The home was rated Good overall and Good in Safe, Effective, Caring, Responsive and Well-led. These ratings were unchanged from the previous inspection on 3 April 2017.
Enough trained staff
Inspectors found enough staff on duty, with staffing increased when people's needs changed. Recruitment checks were completed before new staff started.
“The home was well-staffed with enough staff on duty to meet people's needs at all times.” from the report
Kind and personal care
Staff knew people well, took an interest in their lives and supported their choices, dignity and independence.
“We observed numerous caring interactions between staff and people.” from the report
Good healthcare support
Staff worked closely with GPs, nurses and other professionals. Inspectors found that some people's health and mobility had improved.
“Some people's health and mobility had improved at the home.” from the report
Activities and relationships
People could take part in group and one-to-one activities, trips out and community events. Staff also supported people to keep in touch with relatives.
“The home's activities co-ordinator organised a programme of activities and trips out for people.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you assess and update my relative's care plan after they move in?
- 02How do you adjust staffing if a resident becomes unwell or needs end of life care?
- 03How would you support my relative's communication needs, especially if they have difficulty speaking, hearing or understanding information?
- 04What activities and one-to-one support would be available for my relative's interests and preferred routine?
- 05How would you involve my relative and our family in decisions about care and respond if we had a complaint?
This was an unannounced inspection of the care home, including its premises and care, and all five CQC questions; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 5 February 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.
What inspectors found, June 2017
Brookholme Croft Ltd was rated Good; inspectors found kind, safe care, but some medicines and care records needed improvement.
This was an unannounced inspection on 3 April 2017. It was the first inspection after the provider registered under the Health and Social Care Act in March 2017. Inspectors spoke with people living at the home, relatives and staff, observed care, and checked care, medicines and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found a clean and well-maintained environment, suitable staffing, trained staff, safe care and kind relationships. People were supported with their health, food, activities, choices and contact with family.
There were some weaknesses. Checks on certain medicines were not always complete, and some skin cream records did not show clearly whether medicines had been given. Inspectors also found that some meal choices and best-interest decisions were not recorded or explained clearly enough. The registered manager said action had been taken or planned.
Kind and respectful staff
Inspectors saw staff treating people with kindness and respect. Staff supported dignity, privacy, choice and independence.
“Throughout our inspection we observed that staff, were kind and caring, treated people with respect and ensured their privacy and independence.” from the report
Good health support
Staff noticed changes in people's health and sought help from health professionals when needed. Care plans included detailed information about health conditions and care needs.
“People were supported to improve and maintain their health and nutrition.” from the report
Personalised communication
Staff adapted how they communicated, including for people living with dementia or who could not speak easily. This helped people make choices and reduced distress.
“Staff communicated well with people in a way they understood.” from the report
Activities and family contact
The home supported activities based on people's interests and helped people maintain contact with family and friends. Activities included games, exercise, music and reminiscence.
“People were informed and supported to engage in a range of social and recreational activities and maintain their contacts with family and friends who were important to them.” from the report
Approachable management
People, relatives and staff described the management as visible and approachable. The home used monitoring, meetings and surveys to identify improvements.
“The service was well managed and run by a visible, approachable registered manager.” from the report
Medicine records and stock checks
seriousChecks for certain medicines were not always completed, creating an increased risk of misuse. Records for some skin creams did not consistently show whether they had been given as prescribed.
“This meant there was an increased risk of misuse of those medicines.” from the report
Meal choice and involvement
needs fixingPeople had mixed views about the variety and choice of meals. The report found that choices were not always explained or discussed early enough, and the manager agreed to take action.
“We discussed our findings with the registered manager who agreed to take the required action to address people's expressed views about meals in relation to variety, choice and involvement.” from the report
Care plan involvement
needs fixingSome people and relatives were not fully involved in agreeing care plans. Records also did not always show how people's choices and preferences had been obtained.
“This meant people's level of involvement in agreeing their care plan and also relatives' involvement were not clearly identified.” from the report
Best-interest records
needs fixingBest-interest decisions were recorded using a tick-box list kept separately from the related care plans. This made the information difficult for staff to follow, although staff could describe the required care.
“This did not best inform staff to fully ensure people received care agreed in their best interests because it was difficult to follow.” from the report
- 01What changes have been made to ensure medicine stock checks are completed every time?
- 02How do you now record and check that skin creams have been given as prescribed?
- 03How are residents and relatives involved in writing and agreeing care plans?
- 04How are best-interest decisions linked clearly to the care plans staff use?
- 05What has changed about the variety of meals and how people are told about their choices?
This was the first unannounced inspection after registration and covered the overall quality of the service and all five CQC questions. This explanation was written from the published report of 16 June 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.
Every inspection of Brookholme Croft Ltd
2 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017
Registered with the Care Quality Commission on 10 March 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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