Brookfield Care Home

On this page

• 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 the last assessment this key question was rated good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders did not always support the delivery of high-quality, person-centred care. Governance arrangements had not always been effective in highlighting shortfalls, which impacted on the quality of people’s care and support. The service had clear vision and values and collaborated well with partners. The provider was in breach of the legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider’s Statement of Purpose clearly detailed the service’s vision and values, and this was embedded in the polices, staff training and culture. Staff had training in equality and diversity. The management team and staff demonstrated a commitment to person- centred care and improving outcomes for people. Staff meetings were used as an opportunity to refresh knowledge and as an opportunity to discuss ideas to improve the quality of care.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The manager was new in post. They had commenced their application to register with CQC. They demonstrated they had the skills and experience to manage the service and was open and responsive to our feedback. The provider was visible and active in the service and spoke passionately about providing good care and support for people. Staff spoke highly about the new manager. They said they were approachable, supportive and had introduced recent improvements to how the service was run. Comments included, “[Name of manager] is very supportive, they have not been here very long but really care about the residents and staff” and “Things have changed recently for the better, mostly around communication, like handovers.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy in place, which included clear guidance to support staff to ‘speak up.’ Staff confirmed they felt able to raise any concerns. Leaders ensured people knew and were able to exercise their rights.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an up to date recruitment policy and employed a diverse staff team. Human resources processes were in place to ensure staff understood their rights as employees. Staff told us about reasonable adjustments that had been made to support them. Staff feedback was welcomed and the manager had compiled a ‘You said: We did’ report to summarise what action had been taken to reflect staff views and suggestions.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Audits and checks were in place but they had not always been effective in identifying shortfalls. We found regulatory breaches in relation to the management of risk, medicines and good governance. Medicines audits had not reviewed how prescribed thickeners and creams were monitored, which meant the risks had not been addressed. There were multiple examples where care plans were contradictory or lacking in detail. Whilst the new manager had commenced a detailed audit programme, robust action had not always been taken promptly. For example, 1 person’s care plan had been audited in June 2025 and the recommended changes had not been made. This meant people continued to be at risk of poor care. The manager told us they had increased the number of care plans they were auditing and was providing support and mentorship to senior staff to ensure people’s care records accurately reflected their needs. The provider had policies in place, which were regularly reviewed. The manager was very responsive throughout the assessment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider collaborated with local authorities who commissioned care and health and social care providers. They also worked closely with places of worship, schools and the local hospice. The care home was part of a wider residential community and people had access to a club house, which boasted facilities such as a swimming pool, gym and bar.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider had not demonstrated continuous improvement and the overall rating at this assessment has changed from good to requires improvement.

Learning from events and identifying shortfalls was not always in place. There was a dynamic action plan in place to address issues that had been highlighted. We also saw areas of good practise. For example, the provider had been awarded The Gold Standard Framework (GSF) for end of life care. The GSF is an accredited evidence based approach which reviews how well a service is providing care and support to people who are reaching the end of their life. The provider was responsive to our feedback and we were assured they would take action to address the shortfalls we found at this assessment.