CQC report explained · a residential care home
What the CQC found at Cary Brook
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Requires Improvement; inspectors found friendly, clean care but risks from hot pipes, medicines and weak quality checks.
This was an unannounced focused inspection on 15 and 16 June 2023. Inspectors reviewed Safe and Well-led only. They spoke with people, relatives, staff and a health professional, and checked care records, medicines records, recruitment files and management records.
The home was clean and welcoming. People were happy, relatives spoke positively about care and activities, and staff worked well as a team. Staffing levels were kept in line with the provider's planned safe numbers, although there were vacancies and high use of agency staff.
Inspectors found important safety and management problems. Exposed hot pipes had not been identified as a risk. Medicines had not always been stored safely, and some medicines records and protocols were not detailed enough. Quality checks had failed to identify these problems.
The overall rating changed from Good at the previous inspection in 2017 to Requires Improvement. The other three question ratings were carried forward because they were not inspected during this visit.
Positive atmosphere
People were happy living at the home. Relatives spoke positively about the care and activities, and inspectors described a friendly and welcoming atmosphere.
“People were happy living at the home. Relatives spoke positively about the care and activities provided by staff.” from the report
Safe recruitment and checks
The home followed safe recruitment procedures. Equipment, fire safety systems and other building systems were regularly checked.
“Staff were recruited safely. The service was working to recruit to vacant positions. Equipment and fire safety systems were regularly checked.” from the report
Activities and community links
Activities were tailored to people's needs, and the home involved relatives and the local community through meetings, events and outings.
“Relatives told us people were engaged in activities on offer which had been tailored to their needs.” from the report
Hot pipe risks
seriousMultiple exposed pipes in bathrooms had not been identified or risk assessed. The provider took action after the inspection to identify and report them.
“People had not been protected from the risks of hot pipes. We found multiple exposed pipes in individual and communal bathrooms, which had not been identified as a risk to people.” from the report
Medicines storage
needs fixingMedicine cupboards and the medicine fridge had sometimes exceeded recommended temperatures, but actions were not always recorded. This meant the home could not be sure how long medicines had been stored outside those temperatures.
“Medicines were not stored safely, as actions were not always documented when records demonstrated recommended temperatures of medicine cupboards and the medicine fridge were exceeded.” from the report
Incomplete PRN guidance
needs fixingSome guidance for medicines taken when needed was not detailed or personal to the individual. The effectiveness of these medicines was not always recorded.
“PRN protocols did not demonstrate how people may present or communicate additional medicines were required.” from the report
Weak quality checks
seriousEnvironmental and medicine audits had not identified the problems found by inspectors. This was part of the breach of good governance.
“There were systems in place to monitor and improve the quality and safety of care provision. However, these systems were not effective in ensuring shortfalls were identified and addressed.” from the report
High agency use
minorThere were staff vacancies and a high level of agency use. Staff said temporary workers did not know residents as well, although relatives said they had not noticed a difference in care.
“There was a high level of agency use at the service.” from the report
- 01Have all exposed hot pipes been identified, covered or otherwise made safe, and how are you checking this now?
- 02How do you record and respond when medicine cupboard or fridge temperatures go outside the recommended range?
- 03How have PRN medicine protocols been made more detailed and personal to each resident?
- 04How are you making sure staff learn promptly from incidents and understand the actions taken?
- 05What is the plan for filling staff vacancies and reducing reliance on agency staff?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection in 2017. This explanation was written from the published report of 12 July 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.
What inspectors found, September 2017
Cary Brook is rated Good; inspectors found safe, kind and personalised care, with some records and social interaction needing attention.
Inspectors visited without notice on 16 August 2017. They spoke with people living at the home, relatives and staff. They also checked care plans, medicines records, staff files and quality checks.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. People were protected from abuse, supported by enough staff and helped with their health, medicines and daily needs.
Inspectors found kind and respectful care. Staff supported people's choices and provided activities and care suited to individual preferences. The home had improved since the last inspection, when social stimulation and person-centred care were areas for review.
There were two shortfalls. Some risk assessments did not match people's care plans. Inspectors also saw limited staff interaction with people in one communal lounge. The manager said these issues would be addressed.
Kind and respectful care
People told inspectors that staff were kind and looked after them well. Staff protected privacy and dignity during personal care.
“Staff are good, really good actually. Very kind.” from the report
Care shaped around each person
Care plans recorded individual preferences, and inspectors saw staff follow them, including preferred food, seating and personal items.
“Care plans were individual to the person to make sure care and support was tailored to their needs.” from the report
Dementia training
Staff received specialist training and new staff were supported by an induction, mentoring and time to get to know people.
“People benefitted from a staff team who received training which enabled them to provide care safely and gave them the specialist skills required to work with people who were living with dementia.” from the report
Health and end-of-life support
The home had strong links with local health professionals and had systems for supporting people nearing the end of life.
“The home had recently achieved reaccreditation to the 'National Gold Standard Framework (GSF).' They had achieved 'Platinum' status which is the highest award given.” from the report
Complaints were followed up
The home had a complaints process and records showed that concerns were investigated and acted on.
“Records of complaints showed that all complaints expressed verbally or in writing were responded to in a timely manner.” from the report
Risk records did not always match care plans
needs fixingInspectors found differences between some risk assessments and care plans. For one person, the stated frequency of night checks was different in the two records.
“However these risk assessments were not always in line with people's care plans.” from the report
Limited interaction in one lounge
needs fixingInspectors observed staff passing through one communal lounge without entering or engaging with people for 15 minutes. The manager said this was not usual practice and would discuss it with staff.
“For example we sat in one lounge for 15 minutes and observed staff passing the lounge without entering or engaging with people.” from the report
- 01How do you check that risk assessments and care plans always contain the same instructions?
- 02What has changed since the inspection to make sure people in communal lounges receive regular conversation and social contact?
- 03How many staff are normally on each shift, and how do you respond if staffing levels change?
- 04How will you make sure staff continue to use their dementia training in day-to-day care?
- 05How are people's individual preferences, such as food, activities and daily routines, reviewed when their needs change?
This was an unannounced inspection that assessed the overall service and gave ratings for all five areas. This explanation was written from the published report of 13 September 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 Cary Brook
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 15 November 2010.
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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Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
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