Brook Lodge 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 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 questiongood. At thisassessmentthe rating haschanged 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 in relation governance at the service. 

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion. They did understand the challenges and the needs of people and their communities.

However, this had not been fully implemented or communicated to people, relatives and staff at the service. Whilst some people and relatives told us communication had started to improve, others were not confident or had not experienced any improvements.

Supervision and training arrangements were not always effective in supporting staff to understand the changes happening at the service and the culture the provider was trying to work towards.

Leadership was variable, and although some leaders showed appropriate skills, knowledge and experience, this was not embedded across the service. As a result, opportunities to lead effectively with openness, integrity and transparency were not always realised.

The manager had not been registered for very long and was supporting staff with the changes taking place. However, there was also feedback which showed people and relatives were not always assured by the communication within the staff team.

Staff told us the registered manager was approachable and supportive. A staff member told us, “Management has open door policy, and I was able to talk to them about any issues I had and get them resolved.”

People did not always feel confident to speak up or that their views would be consistently heard.

Feedback from staff and relatives was mixed regarding how well the provider listened and responded to concerns. The provider had forums in place such as staff meetings and a recent relatives’ meeting to share information and updates about the service. Some people told us a provider representative attended and made themselves available to discuss any concerns. However, further work was needed to ensure people, relatives and staff felt consistently empowered to raise issues and were assured their voices would be acted upon.

The provider had taken some steps to promote equality, diversity and inclusion within the workforce.

Whilst no staff had raised concerns about diversity and inclusion, some staff felt supported and able to contribute to the service. However, feedback was mixed regarding how inclusive and responsive leadership was to diverse views and experiences. Opportunities to fully engage staff, recognise differences and create an inclusive culture where all voices were valued had not always been maximised. This reflected the need for further work to ensure equality and inclusion were consistently promoted across the workforce.

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.

Quality monitoring and audits took place, but these were not robust enough as they failed to identify the concerns identified during this assessment. Audits had not identified expired medicines, reconciliation issues or records related to medicines taken when required.

Care plan audits had not picked up the inconsistencies in people’s records including risk information, mental capacity assessments, and monitoring charts.

Whilst the provider responded to some of the concerns at the time of the inspection, more work was needed to improve governance processes.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Information was not always consistently shared with partner organisations, and opportunities to work collaboratively to improve outcomes were sometimes missed. Concerns had been raised by the local authority, who were monitoring the service and had provided support to help drive improvement. However, further work was needed to strengthen partnership working and ensure consistent, effective collaboration.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Systems to support learning from incidents were in place; however, these were not consistently effective. We found some incidents had not been captured within the provider’s monitoring systems, resulting in incomplete or inaccurate data. In addition, staff were not always clear about where incidents, including distressed reactions, should be recorded, and records were maintained across both paper and electronic systems which did not always align. This limited the provider’s ability to identify trends, learn and drive improvement in practice.