Brockenhurst

Updated 25 March 2025

Date of Assessment: 26 March to 1 April 2025. The service is a residential care service providing support to older people living with dementia. The inspection was prompted in part by notification of two incidents following which a person using the service died and another person sustained a serious injury. These incidents are subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of these incidents. However, the information shared with CQC about the incidents indicated potential concerns about the management of risks of falls. This inspection examined those risks. We found breaches of regulation relating to the management of risks, administration of medicines, staffing, person-centred care, dignity and respect and management and governance of the service.

There were widespread and significant concerns in relation to risk management, including failure to identify, assess and mitigate risks of falls, environmental risks and risks associated with people’s health needs. Incidents were not effectively monitored and analysed to support learning. Safeguarding incidents had not been consistently identified and reported to ensure external support and transparency. The provider’s internal systems for checking quality were not effective in identifying shortfalls, including in the administration of medicines, poor record keeping and failures in care planning. Staff did not always receive the support they needed and systems for determining the deployment of staff were not effective. This meant people were not always receiving the support they needed, and care was not well personalised. There was a lack of organised activities, and some people were at risk of social isolation.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This service is being placed into special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.

Updated 25 March 2025

Some people said they were not happy because they didn’t always feel safe. We observed people going into other people’s rooms and staff did not always notice or redirect them. One person told us, “It’s always happening.” Another person who was receiving all care in bed, said, “I just have to shout for help when this happens.” This was having a negative impact on people’s privacy and dignity.

There was a lack of guidance for staff in how to support people with dementia. Some people had altercations, resulting in harm or risks of harm to people, but the provider had failed to recognise and report these incidents in line with safeguarding policy. This meant people were not always effectively protected. Staff were not always providing person centred care in the way people needed or preferred. People were not always having a positive mealtime experience. People were not offered choices and staff did not always acknowledge their views or wishes. We observed some poor practice when staff were assisting people at meal times which did not support people’s dignity.

Opportunities were limited for social engagement. There was a lack of activities to provide stimulation and enrichment in people’s lives. Some people were spending all day in their rooms and were at risk of social isolation. One person told us, “It’s my choice to stay in my room but there is nothing to do anyway.” Another person told us, “Staff are kind, but they never sit with us or have a chat.”

People and their relatives were positive about the staff and described them as kind and caring. One person said, “I am happy with my care,” another person said, “The staff are lovely, top notch.” A relative told us, “Mum is safe here, she has her care tailored to her needs we are happy.” While most people we spoke with expressed that they were generally happy with the care, our assessment found elements of care did not meet the expected standard.