Brooklyn House 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 good. 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 legal regulation to good governance.

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.

The provider had a vision which was presented as ‘our values’ and was displayed within the service.

We saw staff communicating effectively and sharing information to ensure people received timely and appropriate care. A staff member told us, “I know and trust my teammates, we provide person centred care, and we do it because we care.”

Leaders did not always have the knowledge needed to lead effectively. For example, the registered manager did not recognise and address safety concerns we found. While we had confidence in the registered manager’s ability to reduce risk following our feedback, continued improvement was needed to ensure they retained overall oversight and actioned risks identified in a timely manner. We were not assured the processes the provider had in place would have identified the areas of improvement found during the assessment.

However, the registered manager demonstrated to staff they were approachable and accessible. A staff member told us, “[Registered manager] is a very supportive manager.”

Relatives told us that if they wanted to raise anything with the registered manager, they were approachable. A relative told us, “I feel I can always speak to [registered manager] if I need to.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had processes to support staff in speaking up and raising concerns. This included policies in relation to safeguarding and whistleblowing.

A staff member told us, “We report things, for example if we think a resident is at risk or someone has been unprofessional, we flag it to the manager.”

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.

Systems were in place to encourage staff feedback, through staff meetings and supervisions. Policies and procedures promoted an equitable workplace.

Staff told us they felt confident in rising concerns. A staff member told us, “[Registered manager] is approachable, and always willing to help.”

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.

The provider’s audit and quality assurance of key areas of service provision did not identify the concerns we found during our assessment. We found concerns including portable oxygen cylinders being stored in an unventilated cupboard near people, an area of hot pipe in an assisted bathroom was not insulated, people had access to substances which could be harmful, radiators had plastic coated metal frames over them which did not stop hot radiators being accessible to people, and poor infection control. People were not always being repositioned in line with the required time regime, and a Mental Capacity Assessment (MCA) had not been completed for a person.

This meant issues were not always monitored appropriately to reduce risk to people and to drive change. We found no harm had come to people. The registered manager responded promptly when we raised our concerns and provided evidence of improvements being made.

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.

Staff told us that they had developed links with the local community, for example, achieving the Veteran Friendly Framework (VFF) and supporting people to access the monthly VFF breakfast club.

The service had a minibus which enabled people to go out for day trips to local attractions or to the seaside.

A relative told us, “They take [person] out to the sea front or into town. I live local and I’ve seen staff out with residents which is reassuring.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation.We found inconsistencies in systems used to identify learning and make improvements were not always effective. For example, quality assurance systems did not identify the concerns we found. This did not enable the provider to measure and improve change, which potentially put people at risk and opportunities to learn lessons and make improvements may have been missed. However, staff told us that they were supported in their development with access to training to enhance their professional growth.