CQC report explained · a nursing home
What the CQC found at Brooklands Nursing & Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and there were enough staff to meet people’s needs. Some records and additional safety checks still needed improvement, including checks on fire equipment and some equipment safety matters.
- Effective?
- Good
- People’s health, nutrition and care needs were generally met, and staff had suitable training and support. Records did not always fully show people’s food and fluid intake or how some decisions were made.
- Caring?
- Good
- People and relatives described staff as kind, patient and respectful. Inspectors saw care that protected dignity, encouraged independence and involved people in decisions.
- Responsive?
- Good
- Care was personalised to people’s needs, preferences and communication needs. People had access to varied activities and could raise concerns through staff or the complaints process.
- Well-led?
- Requires improvement
- The culture was open and supportive, and managers acted quickly when inspectors identified concerns. However, quality monitoring systems had not identified some shortfalls before the inspection.
What inspectors found, December 2022
Rated Good overall; inspectors found kind, safe and personalised care, but the home’s leadership and checking systems require improvement.
Inspectors visited the home without notice on 17 November 2022. They spoke with people living there, relatives, staff and a health professional. They reviewed care and medicines records, watched care being given, and checked the building, staffing and management systems.
People told inspectors they received attentive, respectful and compassionate care. Inspectors found people’s risks, medicines, health needs, choices and activities were generally well supported. Infection prevention measures were also found to be effective.
The main weakness was the home’s checking systems. These had missed some issues with water safety actions, food and fluid records, window safety, radiator covers and firefighting equipment checks. The provider acted immediately during the inspection.
The overall rating was Good. Safe, Effective, Caring and Responsive were each rated Good. Well-led was rated Requires Improvement. This was an improvement from the previous Requires Improvement rating, and the home was no longer in breach of regulations.
Kind and respectful care
People and relatives consistently described staff as caring and compassionate. Inspectors saw staff treating people with dignity and responding sensitively when people became distressed.
“People who used the service told us their lives had been enhanced by living at Brooklands Nursing and Residential Home.” from the report
Personalised support
Staff knew people’s needs, risks, likes and dislikes. Care plans included personal details, and inspectors saw staff putting these preferences into practice.
“People received care that met their individual needs, personal preferences and wishes.” from the report
Good communication
People and relatives said they were involved in care decisions and received regular updates. The home used meetings, surveys, telephone calls, emails and formal reviews to involve people.
“Relatives were particularly positive on the service's effective communication and described a service that used all forms of communication to engage with them.” from the report
Activities and social life
People had a choice of varied activities and outings. Inspectors saw activities that were well planned, well attended and engaging.
“We saw people happily engage in activities that were well-planned and varied.” from the report
Prompt action during inspection
The provider responded quickly when inspectors identified problems. Inspectors said they had confidence that the concerns had been acted on appropriately.
“During our inspection, the provider took immediate action to address the above concerns.” from the report
Quality checks missed problems
needs fixingThe home’s monitoring systems did not identify several issues before the inspection. These included missed actions from a water system assessment, incomplete food and fluid records, and gaps in safety checks.
“The quality monitoring systems the provider had in place had not been completely effective at identifying some shortfalls found at this inspection.” from the report
No registered manager at inspection
needs fixingThere was no registered manager in post when inspectors visited. A manager had applied to CQC to register, and the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What has been done since the inspection to make sure quality checks identify problems with water safety, windows, radiator covers and firefighting equipment?
- 02How are food and fluid records now checked to make sure they are complete?
- 03How are topical medicines recorded when they are applied?
- 04Who is currently responsible for managing the home, and what is the progress of the manager’s CQC registration application?
- 05How will the home show that people and their relatives are involved in care decisions and reviews?
This was an unannounced inspection covering all five CQC questions, prompted partly by concerns about risk management and end of life care; no one was receiving end of life care during the inspection. This explanation was written from the published report of 7 December 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, July 2022
Rated Requires Improvement; inspectors found kind, familiar care but gaps in risk records, medicines and quality checks.
This was an unannounced, focused inspection. Inspectors visited on 17 and 18 May 2022, and inspection activity ended on 30 May 2022. They spoke with people, relatives and staff, and checked care records, medicines records, staff files and management audits.
The home was not always safe. Risk assessments and care records did not always contain accurate, up-to-date information. There were also problems with storing and recording some medicines, including creams, skin patches and a controlled drug.
The home was not always well-led. Its checks and audits had failed to find or correct some problems, including incomplete repositioning charts and gaps in care records. Inspectors found that people generally felt safe and described staff as caring and kind.
The overall rating fell from Good at the previous inspection, published on 19 November 2017, to Requires Improvement. The home must improve, and the provider was asked for an action plan. CQC said it would continue to monitor progress.
Familiar, kind staff
People were supported by staff they knew and felt comfortable with. People and relatives spoke positively about the staff's care and kindness.
“People were supported by a staff team which were familiar to them.” from the report
People felt safe
People and relatives told inspectors they felt safe and that staff responded to requests.
“People told us they felt safe.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including the use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Approachable management
Staff said the manager was supportive and visible. People and relatives felt able to raise concerns.
“Staff told us the registered manager was very supportive, approachable and visible in the service.” from the report
Risk information was not up to date
seriousSome risk assessments had not been reviewed after people's needs changed. This could have led to people receiving unsuitable care and placed them at risk of harm.
“Risk assessments for people had been completed. However, these had not all been reviewed and updated to contain accurate information to guide and direct staff to provide safe, appropriate care and support.” from the report
Medicine records and storage
seriousSome creams were not stored securely or were used beyond their expiry times. Records and guidance for some medicines, including skin patches and medicines given when needed, were incomplete.
“Medicines prescribed for external application such as creams and emollients were not being stored securely to ensure people could not access them and put themselves at risk of accidental harm.” from the report
Weak quality checks
seriousThe home's audits had not identified several problems in care records, risk assessments, medicines records and repositioning charts. This meant management had not reliably acted on issues affecting safety and care quality.
“The provider's governance systems were not effectively used to ensure the quality and the safety of the care people received was monitored and improved.” from the report
- 01Have all residents' risk assessments been reviewed and updated where their needs have changed?
- 02How are creams and other externally applied medicines now stored, checked for expiry and recorded?
- 03What checks are now made to ensure medicines given when needed and skin patches are administered and recorded safely?
- 04How are repositioning charts and other care records checked for missing or inaccurate entries?
- 05Has the planned new electronic care-record system been introduced, and how were existing records reviewed during the change?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published on 19 November 2017. This explanation was written from the published report of 16 July 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 Brooklands Nursing & Residential Home
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Brooklands Nursing & Residential Home →
- July 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Brooklands Nursing & Residential Home →
- November 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- December 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 10 October 2011.
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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