CQC report explained · a nursing home
What the CQC found at Brookview Neurological Centre-Inspire Neurocare (Worcester)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Requires Improvement, improved from Inadequate, but inspectors found continued breaches in care planning, risk monitoring and governance.
This was an unannounced focused inspection on 09 January 2024. Inspectors checked Safe, Effective and Well-led. They spoke with people, relatives, staff and a visiting professional, and reviewed care plans, medicine records, staffing information and audits.
The home had improved since the last inspection. Medicines were managed more safely, staff training and recruitment processes had improved, and people had more activities, community access and involvement in the service.
However, care plans were not always followed. Inspectors found problems with repositioning records, seating guidance, oral care, welfare checks and fluid monitoring. The systems used by managers did not reliably identify these problems.
The overall rating changed from Inadequate to Requires Improvement. Regulations 9, 12 and 17 were still breached, so further improvement is needed before the home can be considered consistently safe and well run.
Medicines
Medicines management had improved significantly. Records showed medicines were given as prescribed, with regular checks and audits.
“Since our last inspection there had been significant improvements in the management and processes of medicines.” from the report
Staff skills
The provider had improved nursing staff training and ensured clinical support was available for people with complex needs such as epilepsy and PEG care.
“Since our last inspection the provider had ensured nursing staff had attended the relevant training courses in order to meet the care needs of people living at the service.” from the report
Activities and community access
People had more opportunities outside the home, vocational opportunities and activities linked to their interests.
“Activities, community access and community links had developed and people were experiencing more vocational opportunities and their wishes and hobbies were being explored.” from the report
Environment
The home was clean, spacious and accessible for people using wheelchairs. People had personalised their rooms.
“The environment was clean, spacious in design and accommodated people's needs.” from the report
Care plans not always followed
seriousInspectors found that some care was not delivered as written. This included repositioning, specific seating guidance and overnight welfare checks, creating a risk of harm.
“Systems were not robust to monitor and mitigate risks to the health, safety and welfare of people using the service and lessons had not always been learnt.” from the report
Oral care
seriousOne person's care plan required oral care four times a day, but records showed support was provided once a day. Inspectors said this put the person at risk of infection.
“A person did not receive oral health support in line with their oral health care plan which put them at risk of infections.” from the report
Management checks
seriousAudits were being completed but did not reliably identify care that was not being delivered as planned. Some problems found at earlier inspections had still not been resolved.
“Measures to monitor the quality of the care provided were not always effective, this meant the management team did not have a full oversight of issues at the service to always drive improvements.” from the report
Fluid records
needs fixingFluid charts had inconsistent entries, making it difficult to tell whether people had reached their daily fluid targets. The provider said it would review and improve the charts.
“Further improvements were required with monitoring people's fluids.” from the report
- 01How will you make sure repositioning, seating guidance and nightly welfare checks are completed exactly as set out in each person's care plan?
- 02What has changed to ensure oral care is provided at the frequency set out in the care plan?
- 03How are you checking fluid charts so that each person's daily fluid target can be confirmed?
- 04What changes have been made to audits so they identify missed care rather than only confirming that checks have been completed?
- 05Who is currently responsible for the home while the manager is going through the CQC registration process?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the overall rating used ratings from the last inspection for those questions. This explanation was written from the published report of 16 February 2024 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, November 2023
Rated Inadequate and placed in special measures; inspectors found serious risks involving medicines, wound care, staff training and management.
This was an unannounced inspection carried out on 11, 14, 19 and 29 September 2023. Four inspectors and a specialist pharmacist visited the home, spoke with people, relatives and staff, and checked care, medicines, training and management records.
Inspectors found people were put at risk by medicines errors, poor wound care and weak checks on risks. Some agency nurses had not had the required checks or training. Nutrition and hydration were not always managed safely, and care plans were not always followed or kept up to date.
There were some positive findings. Staff were often caring, the home was spacious and personalised, people had access to some healthcare and therapy, and the Mental Capacity Act was being followed. However, these positives did not outweigh the serious and widespread shortfalls.
The overall rating fell from Requires Improvement to Inadequate. The home was placed in special measures. CQC said it would usually re-inspect within six months and could take action to prevent the provider from operating if there was not enough improvement.
Kind interactions
Inspectors observed staff treating people respectfully. Some relatives also said permanent staff were good and caring.
“We observed positive interactions with staff treating people with dignity and respect, we saw staff knocked people's doors before entering” from the report
Communication support
People had communication plans and technology to help them communicate with staff and remain independent.
“Staff had good knowledge of people's preferred communication methods and how they could support people to use them independently.” from the report
Mental Capacity Act
The home assessed capacity, recorded consent and held authorisations for people subject to DoLS.
“The provider was working within the principles of the MCA.” from the report
Suitable environment
The home was described as homely, personalised and accessible. It included specialist bathrooms and an independent living flat for rehabilitation.
“Peoples rooms were personalised, homely and represented their hobbies, choices and preferences.” from the report
Infection controls
Inspectors were assured that infection prevention and control arrangements were in place, including safe visiting and use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines errors
seriousPeople did not always receive medicines safely or as prescribed. Inspectors found gaps in medicine records, missed medicines and duplicate doses.
“Some medicines were not administered as prescribed which resulted in people receiving duplicate doses or missing their medicines.” from the report
Wound care caused harm
seriousWound treatment was overdue or not completed as planned. One person developed sore skin after the correct PEG was not fitted promptly.
“This had been documented in the persons daily notes but not shared or actioned by the provider. This caused harm to the person.” from the report
Staff training and checks
seriousSome agency nurses worked without completed checks, induction or specialist training needed for people's complex healthcare needs.
“The provider had not completed Disclosure and barring service (DBS) check or the nursing and midwifery council (NMC) registration checks for 11 agency nurses” from the report
Nutrition and hydration
seriousThe home did not always act quickly when people lost weight or failed to meet fluid targets. Nutrition feeds were not always given at the correct dose.
“The provider had failed to take timely action when a person experienced significant weight loss.” from the report
Complaints not resolved
needs fixingSome complaints and concerns were not recorded, answered or acted on. People and relatives described poor communication and unanswered calls.
“The provider had not ensured people's and relative's concerns and complaints had been responded to.” from the report
Limited activities
needs fixingPeople had few meaningful activities and limited access to the community, vocational opportunities and rehabilitation outside the home.
“There was a lack of meaningful activities organised for people living at Inspire Neurocare.” from the report
- 01What has changed to prevent missed, duplicate or incorrect medicines, and how are medicine records now checked?
- 02How are wound care plans, PEG changes and skin problems monitored and escalated?
- 03Which specialist training have all permanent and agency nurses completed before working with residents?
- 04How are weight loss, nutrition feeds and fluid targets monitored, and what happens when targets are missed?
- 05What community, vocational and personalised activities are now available for each person?
The inspection began as a targeted check on a previous Regulation 12 warning notice, then became a comprehensive inspection covering all five key questions; the report was published on 29 November 2023. This explanation was written from the published report of 30 November 2023 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 Brookview Neurological Centre-Inspire Neurocare (Worcester)
4 rated inspections over 2 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Requires improvement
Read what inspectors found at Brookview Neurological Centre-Inspire Neurocare (Worcester) →
- November 2023Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateWell-led: Inadequate
Read what inspectors found at Brookview Neurological Centre-Inspire Neurocare (Worcester) →
- August 2023Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementWell-led: Requires improvement
- October 2021GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020
Registered with the Care Quality Commission on 30 January 2020.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Worcestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.