What the CQC found at Little Brook House

The home had improved its use of mental capacity assessments and best-interest decisions. It was no longer in breach of the regulation about consent.

“Sufficient improvement had been made at this inspection and the provider was no longer in breach of Regulation 11.” from the report

Training completion had improved and covered subjects relevant to people's needs. Staff also received some practical competency checks.

“Completion rates of training had improved and the training programme available covered a wide range of subjects including dementia awareness, moving and handling, safeguarding and infection control.” from the report

Staff worked with community health professionals and made referrals for assessment and treatment when needed.

“Staff worked closely with a range of community healthcare professionals, and we saw examples where people had been referred to external services for further assessment and treatment.” from the report

Inspectors saw positive relationships between people and staff. Relatives said staff knew people's preferences and treated them with kindness.

“Throughout the inspection, we observed people's relationships with staff, in all roles, was positive and people seemed relaxed and very comfortable with the staff supporting them.” from the report

Inspectors found three medicines errors, problems with variable doses and topical creams, and missing guidance for some medicines given when needed. They could not be assured that people always received medicines as prescribed.

“Medicines were still not being consistently managed safely, and we were not assured people had always received their medicines as prescribed.” from the report

Some risk plans were missing or unclear. Incidents were not always investigated, recorded or used to prevent similar events, including occasions when people left the home unnoticed.

“Risk management plans were not always in place or did not provide staff with sufficient, or accurate, information about how they were to mitigate the risks to people's health and wellbeing.” from the report

Inspectors found a potential safeguarding concern had not been referred to the appropriate outside agencies or CQC. They could not be assured that another concern had been investigated.

“The systems and processes to safeguard people from the risk of abuse or avoidable harm needed to be more robust.” from the report

Some staff records did not include references or a full employment history. The provider had not completed all required recruitment checks.

“The provider had not ensured all of the required recruitment checks were completed.” from the report

Inspectors saw activities taking place, but records did not show that people were consistently supported with regular social and leisure activities. Some relatives and staff wanted more activities and outings.

“However, a review of people's activity records did not provide assurances they were consistently being supported to participate in regular social and leisure activities.” from the report