Brockenhurst

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was previously in breach of the legal regulation in relation to good governance. While some improvements were found at this assessment, and the provider remained in breach of this regulation.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager and consultants acknowledged that they were working on addressing and improving the culture and direction of the service.

Staff told us they had experienced a significant number of changes since the previous inspection, particularly around revised care‑planning systems and new ways of working. They said these changes were starting to improve clarity and consistency in practice, although it was acknowledged by leaders that some longer‑standing staff found it difficult to adapt. Leaders recognised that further time was needed to embed these improvements fully.

One staff member stated that the service had, “always been very old fashioned” but recent changes had started to move the service forward. While staff recognised positive changes under the new manager, some continued to identify the owner, and registered manager, as their primary reference point for leadership. This meant the leadership structure and accountability pathways were not yet fully embedded, and leaders acknowledged further work was needed to build confidence and ensure clear lines of responsibility across the service. One staff member said, “We have had some staff who have worked here for years, and change can be difficult for some people, especially when changes are being made in quite a short space of time. It’s a slow process; it’s not going to happen overnight.” One professional said, “I think there are some staff that are maybe reluctant to change, unfortunately I think this may be due to working at the home for a long time and being under the care of the previous management and their relationship with them, this does concern me that the previous managers presence in the home may impose of the positive measures the new manager has put in place to move forward.”

Staff told us that care plans were now clearer and expectations about their roles were better defined. Staff described the culture as becoming more open, modernised and better aligned with people’s needs. Leaders had taken steps to develop a clearer shared direction and strengthen the culture within the service. The manager was prioritising engagement and direct working with staff to support this development. One professional said, “The external Care Consultants have been instrumental in enabling progress and supporting (manager) to overcome previous systemic barriers.” Leaders had begun to improve communication with staff, including holding staff meetings to share information, gather feedback and discuss recent changes. Staff said they generally felt able to speak up and raise concerns. However, some reported that they did not always receive consistent support from leaders due to competing demands on managerial time.

Following the last inspection, conditions were placed on the providers registration that required them to maintain the ongoing services of a consultant who specialised in supporting the management of care homes for people with dementia. The consultant was required support the management of the service, including, but not limited to, the assessment, monitoring, review and mitigation ofrisks relating to the health, safety and welfare of service users.

At the time of the inspection, consultants were supporting a manager who had been recruited since the last inspection. Leadership confirmed that the manager planned to seek registration with the CQC to assume the governance and oversight of the service. The manager acknowledged that, although they had progressed in their development, they did not yet possess the appropriate knowledge, experience and skills to lead independently and effectively. For example, oversight and completion of the services quality assurance systems and audits remained with the consultants. Continued development was needed to strengthen leadership capacity and ensure managers were consistently able to provide the support, guidance and oversight required to sustain improvements.

Leadership capacity was still developing. Some staff reported that they did not always receive timely support, as managers were balancing multiple operational responsibilities. One staff member told us they sometimes felt unsure about decisions when senior support was not immediately available, and said they wanted leaders to be more consistently present and involved in day-to-day practice.

Leaders demonstrated a commitment to improving the quality and safety of the service, and staff told us they had seen positive changes since the new manager took up their role. Staff said the leadership approach had become more open and supportive, and that recent changes were helping to modernise how the service operated. They described the manager as approachable and willing to listen, and most felt able to raise concerns or seek advice when needed.

Despite the pressures, staff described leaders as compassionate and committed to improving the service. They said the manager promoted a culture of openness and was responsive to concerns raised. Staff also told us they felt supported to speak up, contribute ideas and take part in discussions about changes to care planning and working practices.

Staff told us they felt increasingly able to raise concerns and speak openly about issues affecting the quality and safety of the service. Staff said they were encouraged to share their views during staff meetings, where leaders discussed recent changes, gathered feedback and invited suggestions for improvement. This contributed to a more open culture in which staff felt their voices were valued.

Staff described feeling comfortable approaching leaders and said they were confident concerns would be taken seriously. One staff member told us they felt “100 per cent” able to speak up and had opportunities to raise questions or concerns during meetings about new systems and changes to care‑planning processes.

Leaders promoted an inclusive working environment where staff felt respected and able to contribute regardless of background or role. Staff told us they felt comfortable raising concerns and were confident they would be listened to. Leaders had begun strengthening communication across the team, including holding staff meetings to discuss changes, gather views and understand how new processes were affecting staff. This helped create a more open culture where staff felt able to express their opinions and share feedback. One staff member said, “We had a staff meeting yesterday about all the new changes, how staff are feeling and coping. We talked about the new care plans, things we can do better, things that need improving, and we were asked for suggestions and if we had any questions.”

Staff described positive working relationships and said they supported one another well. They told us the culture of the service was becoming more modern and open as new systems were introduced and expectations became clearer. Staff felt they could approach leaders when needed, and several described the manager as supportive and accessible, despite pressures on staffing. Staff were aware of the need to support people’s preferences, including cultural and religious needs.

Leaders had begun to strengthen governance arrangements, and there was evidence of improving oversight across key aspects of the service. Systems for reviewing incidents, audits and care documentation had been introduced or revised since the last inspection, with leaders and external consultants working together to support improvements in quality, safety and record‑keeping. However, these systems were not yet fully embedded, and further work was needed to ensure they were applied consistently.

For example, leaders used audits to monitor performance and identify gaps, although these varied in quality and consistency. However, wider governance tools, such as risk‑management processes, escalation pathways, and oversight of clinical assessments, were still developing and had not yet achieved sustained, reliable practice in areas such as skin integrity, recognition of deterioration, and care‑plan accuracy.

Governance, management and accountability arrangements were not yet firmly in place. The manager relied significantly on the support of external consultants to manage and oversee risk management processes and quality assurance systems. The provider had invested in external consultancy support to help stabilise the service and develop the managers’ competencies. Staff told us these consultants had supported improvements to care planning, staffing structures and quality assurance systems. This had strengthened leadership capacity, but some progress under the manager remained vulnerable to the eventual withdrawal of external support. Leaders acknowledged that the manager was not yet ready to fully assume and oversee many governance duties, such as quality assurance systems and oversight. One professional said, “The external Care Consultants have been instrumental in enabling progress and supporting (manager) to overcome previous systemic barriers. My concern is that some improvements may be more challenging to sustain once this external support ends. (The manager) is committed to continued development and care enhancement for all the residents within the home but may encounter additional obstacles as she moves forward.”

Leaders had worked proactively to reengage with external professionals and community partners to support people’s health and wellbeing.

Leaders had reviewed people’s care and support and ensured that appropriate referrals had been made to external professionals such as GPs, Mental Health team, District Nurses and Speech and Language Therapists (SaLT). Health professionals told us the management team were engaged, responsive and valued the guidance offered. One professional said, “Brockenhurst management and senior care staff have always been very engaged with the team and the whole process. The importance of the reviews have been clearly understood. Any recommendations we make have been valued and acted on, suggested actions are followed through. Brockenhurst have always openly welcomed feedback and I have always felt there has been a genuine desire to use the feedback to learn and improve.”

External clinicians described positive working relationships with the service and said that staff acted on advice relating to care planning, escalation processes and the recognition of deterioration. One professional said, “I find the staff are approachable and when I raise concerns they are responsive to this. They are willing to learn. (The manager) has stepped up and is keen to make positive changes.” They highlighted that collaboration with the service had strengthened over recent months and that staff were receptive to training and support offered by community health services.

Leaders had taken steps to strengthen learning and improvement across the service. Working with external consultants, they had begun identifying weaknesses in quality, safety and record‑keeping and had introduced new systems to support improvement.

Further learning and development were still needed to ensure improvements were sustainable. Policies and governance tools were still developing, and staff understanding of new processes was not yet embedded. Induction processes remained at an early stage and did not consistently support new or agency staff to understand their roles, responsibilities or safety expectations. The manager continued to rely heavily on external consultants for quality assurance, risk management and governance activities, and further development was needed to build their capability and confidence so they could assume full leadership responsibility when consultancy support ends.

Systems for involving people and their relatives in improvement were also not yet well established. The provider had not implemented regular formal meetings or structured opportunities for people and relatives to share their views, contribute ideas or influence development work. While people told us they felt comfortable raising concerns informally, there were limited mechanisms to ensure feedback was routinely gathered, analysed and used to drive learning and improvement.

Staff told us they had seen a number of changes over recent months, including revised care planning documentation, new assessment tools‑ and improvements to day-to‑day working practices. These developments had started to support greater consistency across the service, although leaders recognised that fully embedding these changes would take time.

Leaders acted on feedback during the assessment. Issues identified with medicines, environmental safety and clinical oversight were addressed, and staff were encouraged to raise concerns and share ideas through staff meetings and informal discussions. Visiting professionals also reported positive engagement with the service, stating that leaders valued external feedback and used it to drive improvements in care planning, escalation processes and recognition of deterioration.

Leaders acknowledged that improvement initiatives were still at an early stage and required ongoing support, staff development and clearer involvement of people, relatives and staff. They remained committed to building the service’s capacity to learn, innovate and sustain improvements independently.