CQC report explained · a residential care home
What the CQC found at Brookvale House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safeguarding policies, trained staff and an action plan following a safeguarding investigation. They were assured about the home's infection prevention and control arrangements.
- Effective?
- Good
- This key question was not assessed in this targeted inspection.
- Caring?
- Good
- This key question was not assessed in this targeted inspection.
- Responsive?
- Good
- The home had a complaints policy. The one complaint received that year had been investigated straight away, with lessons learnt to improve communication.
- Well-led?
- Good
- There was no registered manager because the previous manager had recently left. A new manager had applied for registration, and staff described the management structure as clear and approachable.
What inspectors found, December 2020
Previous overall rating remains Good; this targeted inspection was not rated and found no evidence of harm.
The inspection took place without notice on 29 October 2020. One inspector observed the home, spoke with the new manager and a staff member, reviewed safeguarding and complaints records, and later spoke by telephone with relatives and staff.
The inspection focused on specific concerns about the lack of a registered manager and how safeguarding alerts and complaints were handled. Inspectors also checked infection prevention and control measures during the COVID-19 pandemic.
Inspectors found safeguarding procedures, staff training and complaint systems in place. They found that a complaint had been investigated promptly and that lessons had been identified. Infection control arrangements were also judged reassuring.
This was not a full inspection. The overall rating did not change and remains Good from the previous inspection. The areas inspected were marked 'Inspected but not rated'.
Safeguarding arrangements
Staff had completed safeguarding training and knew what to do if they suspected abuse. The new manager had worked with the local authority and put an action plan in place after an investigation.
“Staff had completed training in safeguarding adults and were aware of the different types of abuse and what they would do if they suspected or witnessed abuse.” from the report
Infection control
Inspectors were assured that the home had measures covering visitors, distancing, personal protective equipment, testing, cleaning and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Handling complaints
The home investigated the one complaint it had received that year straight away and identified lessons to improve communication.
“We saw that the complaint had been investigated straight away and lessons had been learnt to improve communication.” from the report
Positive staff views
Staff said the management team was visible, approachable and clear about its roles. Relatives told inspectors that people were safe and happy.
“Staff felt that the management team was approachable and visible in the home.” from the report
No registered manager at the inspection
needs fixingThe previous registered manager had recently left. A new manager had applied to become registered, but the process was still in progress when inspectors visited.
“There was not a registered manager at the home as the previous registered manager had left recently.” from the report
- 01Has the new manager's application to become the registered manager been completed, and who is currently responsible for the home?
- 02What changes were made as a result of the safeguarding investigation and its action plan?
- 03How are safeguarding alerts reviewed now, and how are lessons shared with staff?
- 04How are complaints recorded, investigated and used to improve communication?
- 05What infection control arrangements are currently in place, including testing, personal protective equipment and outbreak management?
This was a targeted inspection of specific parts of Safe, Responsive and Well-led, plus infection control; it did not reassess the full key questions, and the previous overall Good rating remained unchanged. This explanation was written from the published report of 10 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.
What inspectors found, May 2018
Brookvale House was rated Good; inspectors found safe, kind and personalised care, with some cleaning and odour issues noted.
Inspectors visited on 3 and 4 April 2018 without giving notice. They spoke with people living in the home, visitors, staff and the registered manager. They observed care and checked care plans, recruitment records and quality audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable staffing, safe medicines support, trained staff, appropriate care plans, good food and access to healthcare.
Staff were described as caring and respectful. People were offered choices, personalised activities and support that reflected their needs. End of life care was found to be kind, gentle and personal.
The home had improved since the previous inspection in December 2016. Earlier concerns about consent records and care plans had been addressed, and there were no longer any breaches of regulations.
Staffing and safety
Inspectors found suitable numbers of staff and appropriate recruitment checks. Risk assessments and building safety checks were also in place.
“People's needs were met by suitable numbers of staff.” from the report
Kind and respectful care
Staff showed patience when people were distressed or reluctant to eat. They respected privacy, dignity and people's choices.
“Staff developed caring relationships with people using the service.” from the report
Personalised support
Care plans included people's history, preferences, communication needs and healthcare requirements. Activities were adapted for people's interests and choices.
“People received personalised care that was responsive to their needs.” from the report
Training and healthcare
Staff had training for their roles, including dementia awareness. People could access GPs, nurses, dentists and other health professionals when needed.
“People were supported by staff who were trained appropriately for their role.” from the report
Cleaning improvements needed
needs fixingThe home had identified that cleaning schedules needed improvement and planned an action plan. Inspectors also found an unpleasant odour in some areas.
“the cleaning schedules were recently identified as needing to be improved and the registered manager was going to develop an action plan to address the shortfalls.” from the report
Unpleasant odour
minorSome furniture and carpets needed replacing because normal cleaning was no longer enough. Refurbishment was ongoing.
“We advised the registered manager that we found there was an unpleasant odour in some areas of the home.” from the report
- 01What action was taken after inspectors found an unpleasant odour in some areas of the home?
- 02Has the action plan to improve cleaning schedules been completed, and how is cleaning now checked?
- 03How often are medicine errors reviewed, and how are staff retrained or reassessed after an error?
- 04How many staff vacancies are there now, and how often are agency staff used to cover shifts?
- 05How do you make sure care plans and consent records remain accurate and up to date?
This was an unannounced inspection of the care and premises, covering all five CQC questions and the overall rating. This explanation was written from the published report of 19 May 2018 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 Brookvale House
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- December 2020Inspected but not ratedcurrent ratingSafe: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- May 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2015
Registered with the Care Quality Commission on 2 February 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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