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Inspection Summary

Overall summary & rating


Updated 7 October 2020

About the service

Brooklands is a residential care home providing accommodation and personal care to four people with learning disabilities. The service can support up to nine people. Brooklands accommodates people in one adapted building consisting of a converted period house. Bedrooms were located on the first and ground floor of the property. A communal lounge, kitchen and conservatory/ dining room were on the ground floor.

The service has been developed taking into account best practice guidance and the principles and values underpinning Registering the Right Support. The home is located close to Evesham town centre and the facilities provided for the community.

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

People living at Brooklands did not receive a safe, effective and well led service. The registered provider had not ensured oversight was in place to maintain people’s safety and welfare. Shortfalls identified as part of previous inspections regarding the service were not always actioned to prevent further or similar occurrences.

Care plans and risk assessments did not contain up to date and accurate information to inform staff how to provide safe care to people. Records were not always completed to evidence the care and support people had received and in line with people’s health care needs.

People were at increased risk of experiencing harm because the systems in operation failed to identify concerns with the premises and repairs were not promptly actioned. Fire prevention best practice was not adhered to. Risks regarding the building were not always considered and were not in line with the provider’s own procedures. Practices to reduce the risk of Covid-19 infection within the home were not always implement by staff members and areas of the home were not able to be effectively cleaned.

Safe systems were not always implemented to ensure staff were aware of protocols regarding people’s medicines. Accurate records regarding people’s medicines and prescribed creams were not always maintained placing people at risk.

The dependency needs of people were not considered to establish the required staffing levels to meet these needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The service didn’t always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support. For example, in addition to restrictions in place due to the Covid-19 pandemic people’s freedom of movement without supervision was further restricted. Terminology used in recording and while supporting people was not always in line with person-centred care.

Staff had received training in line with the provider’s procedures. Skills and knowledge were not always in place during the inspection and within the record keeping and management seen.

The governance of the service had not ensured people received the care and support required to meet their individual needs. Systems in operation had not identified shortfalls and had not driven continual improvement.

The provider had failed to notify the Care Quality Commission of certain important events which had occurred within the home as required by law.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 03 October 2019). There were two breaches of regulations and we served a Warning Notice highlighting the areas requiring improvement and

Inspection areas



Updated 7 October 2020

The service was not safe.

Details are in our safe findings below.



Updated 7 October 2020

The service was not effective.

Details are in our effective findings below.


Requires improvement

Updated 7 October 2020


Requires improvement

Updated 7 October 2020



Updated 7 October 2020

The service was not well-led.

Details are in our well-Led findings below.