About the service Brooklands Nursing and Residential Home is a care home which provides personal and nursing care to people aged 65 and over who may be living with dementia, a physical disability or sensory impairment. The service can support up to 70 people. At the time of this inspection there were 59 people receiving support.
The home is built over three floors with one floor being dedicated to people living with dementia. All bedrooms have a wash hand basin and many have toilet facilities. In addition, there are shared bathroom facilities and shared living areas on each floor. Within the grounds there is an enclosed and accessible garden.
People’s experience of using this service and what we found
Risk assessments did not always include all necessary information to mitigate risk of harm to people. Where change had occurred, accurate updates of risk assessments had not always been conducted.
The quality assurance processes and systems in place were not robust and did not drive change and improvement to the quality of the service. The audits had not identified shortfalls in medicines, monitoring charts or risk assessments.
The provider had identified the current electronic system was less effective in recording person centred information. The provider advised the inspector a new system had been identified which was due to be implemented in the service.Training had been planned for all staff and a process was in place to transition and review all records when moving these to the new system.
People were supported by a staff team which were familiar to them. People and relatives were complimentary about the staff who they felt were caring and kind. People told us they felt safe. People, their relatives and staff felt the manager would address any concerns they had.
Staff had received an induction and training which prepared them for their role. Staff were confident in reporting concerns internally and to external organisations. Staff felt supported by the registered manager, who they found to be approachable and visible in the service.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for the service under the previous provider was good, published on [19 November 2017].
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We received concerns about the provider’s governance systems and oversight of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Brooklands Nursing and Residential Home on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to care planning, risk assessing, and the quality assurance processes at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.