Brookfields Private Nursing 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 our last assessment we rated this key question outstanding. 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 service was in breach of 1 legal regulation in relation to governance systems.

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 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.

Leaders and staff understood the provider’s aims to care for people respectfully and sensitively and provide care tailored to people’s personal needs. Leaders involved staff in the development of the service and invited their input into finding solutions. This helped create an inclusive atmosphere for staff to work in.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, development of some staff roles was needed to ensure leaders could confidently delegate tasks and to help with the workload in the service.

Improvements to various aspects of the service were coordinated by the registered manager with support from other staff. This entailed improvements to care plans, and records and governance systems. The registered manager recognised this was a considerable workload and there had been some impacts to their day-to-day duties, for example, not being able to always ensure the timely review of accidents and incidents. They told us they were making plans to ensure other staff members could gain the skills and confidence needed so that some tasks such as care planning could be delegated confidently to them.

Staff spoke highly of the registered manager and leaders at the service. The registered manager told us they had recently joined networks to help support them to stay connected to good practice. Leaders were capable, compassionate and inclusive however some aspects of leadership, including staff roles and accountability, were still being embedded and developed further.

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

Staff all told us they would feel confident to raise any concerns and that these would be acted on by leaders in the service. Staff understood the principles of ‘whistle-blowing’. Whistle-blowing procedures protect staff from being treated unfairly by their employer if they have raised genuine concerns about a person’s care. This helped to ensure there was a culture where staff felt able to raise concerns.

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.

Staff felt well treated and valued. Leaders provided examples of where staff were supported to work flexibly and change roles to support their work life balance.

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

Systems and processes were not always operated to identify shortfalls in the service and ensure risks were mitigated and improvements made. Some shortfalls had been recently identified by partner agencies, and the provider was working to implement these improvements. However, we found some actions previously identified by partner agencies had not been taken. An infection prevention assessment tool had identified personal protective equipment (PPE) stored in the sluice should only be used for use within the sluice and not used outside in clean areas. The provider’s PPE policy stated PPE should be stored to prevent contamination. However, staff told us they still used PPE from the sluice for general care. Leaders told us they believed there was little risk from how they stored PPE and no further actions had been taken to store PPE for general use outside the sluice in line with advice form partner agencies and the provider’s policy.

The provider is required to notify CQC of certain events and incidents. They are important as they help to show the provider is working in a transparent and open way. We found examples where notifications had not been submitted. Systems and processes had not been operated effectively to ensure notifications were submitted to CQC as required.

We found records were not always accurate and complete. Some care plans and risk assessments did not accurately reflect people’s falls history and cleaning records were not dated. Records for people’s food and fluid intake and the frequency of their repositioning were not made in a consistent manner and so could not be relied on to be accurate or complete.

We found cleaning products had been left in areas people could access. We found medicines had been left unattended in a communal room people could access. Systems and processes were not operated effectively to ensure these items had been stored in line with health and safety regulations and good practice standards to help prevent risks to people.

Reviews of accident and incidents by leaders did not always happen in a timely manner. This meant there was not always timely scrutiny of whether all appropriate steps had been taken. For example, leaders confirmed staff had not recorded that they had informed family members of an incident and leaders checked whether this had happened only when prompted by the inspection.

Not all relevant information had been used to inform trends and potential improvements in the service. For example, when people had voiced dissatisfaction with aspects of their care this, along with how the issues had been resolved, had not been recorded in a way that would help inform trends on complaints and safeguarding. Information on the times and locations of people’s falls was available on the provider’s computer system, however, there was no evidence this had been analysed and used to help inform falls management strategies. This meant not all information that could potentially help to improve the service was being used in that way.

The provider’s systems to track and monitor staff training and whether or not staff were compliant with the provider’s expectations were not yet fully effective. Leaders were developing a system to manage this at the time of our inspection. However, leaders told us they had not yet established a full overview and there were gaps in staffs’ training records. Whilst leaders assured us staff training was planned in the areas needed, the systems we were shown could not for instance show how long staff training in areas such as basic life support had been expired for before staff completed training soon after our inspection. This meant the system did not provide assurances staff training had always been kept at acceptable compliance levels.

The provider’s current audits were not effective at identifying shortfalls and driving improvements in the quality and safety of the service, for example they had not identified all of the issues we found on our inspection. Leaders told us audits were in development and they wanted to develop them further from the standard templates currently used. Systems and processes were not yet effective at assessing, monitoring and improving the quality and safety of the service.

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.

Leaders were working with partner agencies to improve the service following their feedback. An action plan was in place to help achieve the necessary improvements.

The service had regular links with the community matron and GP. Feedback from partners included, how well the staff had engaged with them and that staff were proactive in response to people’s needs and escalated to other services appropriately.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.However, they were working to make improvements.

The registered manager was working to make improvements following recent audits and support from partner agencies. Some improvements could be seen, for example in some aspects of medicines management, however, these improvements were still being embedded at the time of our inspection.