Brookholme Care Home

Updated 24 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was completed by one inspector and a nurse specialist. We also had the support of an Expert by Experience who completed telephone calls to relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Brookholme Care home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Brookholme Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed notifications we had received about the service and spoke with the local authority for this location to obtain their feedback. We used all this information to plan our inspection.

During the inspection

We spoke with some staff on site and other staff by telephone after the inspection. These included, eleven members of staff including senior care staff, registered manager, domestic, the cook, activity workers and care staff. We reviewed a range of records. This included six people's care records and multiple medication records. We looked at three staff files in relation to recruitment.

We also spoke with two people who received care and observed staff providing care to people.

After the inspection we looked at training data and quality assurance records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

The day after the inspection the Expert by Experience made telephone calls to eight relatives, to obtain their views on the care their relative had received.

Updated 24 June 2022

About the service

Brookholme Care home is a residential care home providing personal care and accommodate for up to 40 people. The service provides support to older people and people with physical needs or living with dementia. At the time of our inspection there were 36 people using the service.

People’s experience of using this service and what we found

The providers quality processes were not always in place or the required audits used to identify where changes may be needed. The home was not cleaned to a high standard and we saw some areas of the home required attention to detail to--in ensure it looked well cared for. Cleaning schedules and oversight of the home had not been completed to ensure the standards were being met.

Other audits had been used to reflect on people’s safety. For example, reviewing accidents and incidents. Measure were put in place to mitigate risks, or observe people post fall.

Medicines were managed safely by staff who had completed training and had their competencies completed.

There were sufficient staff to meet the needs of people, following a dependency tool being completed to access the levels of need. Staff were recruited safely and completed induction and training to support their roles.

Learning from incidents had promoted further training to ensure all staff had the required skills and knowledge when completing moving and handling techniques.

The provider worked with health and social care professionals. Referrals were completed and their advice detailed in the care plans and shared with staff.

People, relatives and staff views were considered and used to drive changes. All the relatives we spoke with complimented the staff on their kindness and attitude. They reflected on the range of activities available, communication and information around managing COVID 19.

Overall infection prevention and control was managed well. People’s safety was considered, and risk assessments were in place. Staff understood the importance of protecting people from harm, safeguards had been investigated and any learning shared.

All complaints were investigated, and duty of candour considered. Notifications to us were completed to enable us to monitor the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update: The last rating for this service was Good (published 27 July 2018).

Why we inspected

The inspection was prompted in part due to concerns received about safety and risks to people. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements in relation to their auditing processes to drive improvements and maintain quality.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained the same, however we have rated the well led section as requires improvement.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Brookholme Care Home on our website at www.cqc.org.uk.