CQC report explained · a nursing home
What the CQC found at Brownlee Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks and medicines were generally managed safely, but agency staff did not always know people's needs and risks, and risk records needed improvement.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Leadership had improved since the last inspection. Staff felt supported and able to speak up, while quality assurance systems were being reviewed to make them more robust.
What inspectors found, March 2022
Rated Good; inspectors found safe care and improved leadership, but agency staffing, risk records and PPE use needed attention.
This was an unannounced focused inspection on 14 and 17 February 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicine records, staff records and service documents.
The home was rated Good for Safe and Well-led. People said they felt safe, medicines were managed safely, the building was maintained and there were enough staff on duty. However, agency staff did not always know people's needs and risks, and their use was putting pressure on regular staff.
The home was clean and had infection control procedures, but face mask use was inconsistent. Leadership had improved from Requires Improvement to Good, although work to strengthen quality checks and risk management was still under way.
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding procedures and incidents were investigated.
“People told us they felt safe living at the service.” from the report
Medicines were managed safely
Medicines were stored safely, records supported administration, and staff had received relevant training.
“Medicines were safely stored. Records to support safe administration of medicines were in place.” from the report
Clean environment
The home had cleaning routines and regularly cleaned high-risk touch areas. Infection outbreaks had been managed using good procedures.
“PPE was available throughout the service. Staff had received training in donning and doffing. Good cleaning regimes were place.” from the report
Improved leadership
The well-led rating improved from Requires Improvement to Good. Staff felt listened to and supported, and the provider was taking action on identified improvements.
“At this inspection the rating has changed to good.” from the report
Kind and attentive care
People and relatives described staff as patient, gentle and attentive. Relatives said they were included in their loved one's care.
“They [staff] look for different ways of helping people.” from the report
Agency staff did not always know people's risks
needs fixingRegular staff knew people well, but agency staff did not always know individual needs and risks. Inspectors recommended reviewing how this information is shared.
“Agency staff did not always know people or the risks they faced.” from the report
Agency staffing pressures
needs fixingThere were enough staff on duty, but the high use of agency staff put pressure on regular staff. The deployment of agency staff needed review.
“The high use of agency staff put regular staff under increased pressures.” from the report
Inconsistent mask use
needs fixingSome staff did not use face masks consistently, and visitors could enter without masks. The provider was addressing this.
“The use of face masks was inconsistent with staff. Visitors were able to enter the service without face masks.” from the report
Risk records needed improvement
needs fixingRecords used to oversee and manage risks were not fully effective. The provider had identified this and work was under way.
“Records to oversee and manage risk needed further improvement.” from the report
Gaps in induction records
minorSome staff induction records did not show observation and supervision of new staff. The report does not say this caused harm.
“There were some gaps in staff induction records relating to observation and supervision of new staff.” from the report
- 01How do you make sure agency staff understand each person's needs, risks and care plan before working with them?
- 02What has changed to reduce reliance on agency staff and ease pressure on regular staff?
- 03How are you checking that staff and visitors follow the face mask requirements?
- 04What improvements have been made to records used to assess and manage risks?
- 05How do you record observation and supervision during new staff induction?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the last inspection. This explanation was written from the published report of 10 March 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, January 2022
Brownlee Court was inspected but not rated; inspectors found good infection prevention and control arrangements.
This was an announced, targeted inspection on 7 January 2022. Inspectors gave the home 24 hours' notice.
The visit focused only on infection prevention and control. The home was being used for people discharged from hospital with a positive COVID-19 status.
Inspectors found the premises clean and tidy. Visitors were screened, staff used protective equipment correctly, social distancing was promoted, and the home had supplies of protective equipment.
The home was inspected but not rated. This report does not give an overall quality rating or ratings for all five areas of care.
Clean premises
Inspectors found the home clean and tidy, with regular cleaning taking place.
“The premises were clean and tidy, with regular cleaning taking place.” from the report
Protective equipment
There were plentiful supplies of protective equipment, and staff were seen using it correctly.
“Plentiful supplies of personal protective equipment (PPE) were in place, and staff were seen using this correctly.” from the report
Visitor controls
Visitors were screened to reduce the risk of infection spreading.
“Visitors were screened to reduce the risk of them spreading infection.” from the report
Safe admissions and visits
Inspectors were assured that admissions and visits were being managed in line with current infection control guidance.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staff pressures linked to COVID-19?
- 02How do you arrange testing for people living in the home and staff?
- 03What checks are made before someone is admitted to the home?
- 04What are the current arrangements for family visits?
- 05Can you show me the most recent full inspection report and explain any ratings that are not covered here?
This was a targeted inspection of infection prevention and control and did not provide a full rating for the other areas of care. This explanation was written from the published report of 14 January 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 Brownlee Court
6 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Inspected but not ratedSafe: Inspected but not rated
- March 2021GoodSafe: GoodWell-led: Requires improvement
- October 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2018Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- October 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2019
Registered with the Care Quality Commission on 22 November 2019.
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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