Brook Lodge Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 46 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Care records were not always accurate or consistent, and we found instances of contradictory information across documentation. This meant we could not be assured staff were accessing reliable and up-to-date information about people’s assessed needs and preferences. For example, care plans contained conflicting guidance regarding people’s repositioning requirements and the equipment needed to support them safely.

During observations we noted staff consistently failing to support 2 people to use the equipment needed to help them mobilise safely despite the care plan clearly indicating this was necessary. These inconsistencies increased the risk of unsafe or inconsistent care delivery and meantpeople’s needs may not have been met in a coordinated, person-centred way.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Monitoring charts were not consistently completed, contained gaps, or did not reflect people’s current needs and presentation. This meant there was limited assurance staff had accurate oversight of people’s wellbeing or could identify changes and respond appropriately. In addition, records did not consistently demonstrate how people’s preferences, choices, and what mattered to them were accurate or embedded into care delivery.

People’s nutrition and hydration needs had been considered and recorded within care plans; however, we received mixed feedback about the quality of the food. A person told us, “The food can be cold by the time it has got to you.” A relative said, “The food was poor, but I think it is improving and they have more staff serving the food now, so people get it promptly.” Relatives told us food had been discussed at a recent relative meeting, and they hoped this would improve things.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Systems for sharing information were not consistently effective, and staff told us communication, including handovers, was often limited or lacked detail. This meant staff did not always have access to up-to-date information about people’s needs, increasing the risk of inconsistent care. In addition, the provider did not always ensure information related to people’s assessments and care needs was shared appropriately when people moved between services or were supported by different teams, such as temporary staff. This lack of continuity and information sharing meant people’s needs may not have been fully understood or consistently met.

Improvements were required to ensure coordinated, joined up working across teams and services to promote safe, effective, and person-centred care.

A staff member told us, “Handover is not detailed we do not get the updates.” Another staff member said, “We are just expected to get on with it. We have to find out which staff can show us who people are and how things work."

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Care plans reflected people had access to healthcare professionals such as dentists, opticians and healthcare professionals as required, to promote good physical health. However, there was limited evidence staff held regular conversations with people (and, where appropriate, relatives) about their health needs. Relatives told us they were not always kept informed about their family members health needs. A relative said, “If [family member] says they have not been well when I speak with them, I often don’t find out until I visit. They will tell me they have seen a GP, but I don’t know why, and I have power of attorney for health so feel I should be made aware.” Another relative said, “They never tell me what professionals come in, or what happened.”

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves.

Clear and consistent guidance was not always available to staff on how to monitor people’s health and wellbeing proactively. For example, guidance relating to repositioning was unclear, with conflicting timeframes recorded within care documentation. This created a risk of inconsistent practice. In addition, a review of monitoring charts identified gaps in recording, and in some cases, people were left in the same position for extended periods. These issues meant the provider could not be assured people were receiving safe, consistent, and effective care that met their needs. A senior staff member told us they were aware of the gaps and had organised a staff meeting to discuss this.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Mental Capacity Act (MCA) documentation was not always robust or consistently applied. We found multiple decisions recorded on single MCA assessments, which limited clarity and decision-specific analysis. In some cases, restrictions had been implemented for individuals who were assessed as having capacity, without sufficient evidence to justify these measures. For example, there was limited information to explain why a deprivation of liberty safeguard [DoLS] referral had been submitted for a person who had capacity, following an incident where they returned late from the community. There was no clear evidence of a risk assessment or a shared agreement between the person and the service about managing such situations documented.

In another instance, a person with capacity had a restriction implemented following discussions with a relative. Staff reported they were not consistently implementing this, as the person wished to retain control and had capacity to make that decision. Although both issues were addressed at the time of inspection, these concerns highlighted a lack of consistent understanding and application of MCA principles, particularly in balancing risk, autonomy, and the least restrictive options.