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Inspection Summary

Overall summary & rating


Updated 22 February 2018

Briarcroft Care Home is registered to provide care for up to 20 people. People living at the home were older people, the majority of whom were living with dementia. At the time of the inspection there were 17 people living there.

This inspection was unannounced and took place on 14 and 15 December 2017. The last comprehensive inspection of the service was in August 2016. At this inspection we found breaches of regulations related to person centred care, dignity and respect, the protection of people’s legal rights, safe care and treatment, premises and equipment and quality monitoring. We rated the home as ‘Requires Improvement’ in all five key questions. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider. This required the provider to improve quality monitoring processes by 7 November 2016, due to the serious and major impact on the safety and quality of services people received. We issued requirements for the other five breaches of regulations. Following the inspection in August 2016 we met with the provider who gave assurances of their commitment to improving the quality and safety of the care and support provided to people.

We carried out an unannounced focused inspection on 13 January 2017 to check that improvements to meet legal requirements planned by the provider after our August 2016 inspection had been made. The team inspected the service against one of the five questions we ask about services, “Is the service well led?” We some found improvements had been made. The provider had developed a service improvement plan, with the support of the local authority’s quality and improvement team, and begun a programme of improvements within the home. However, we found there were other areas that required improvement and some of the decisions made by the manager did not promote safety or protect people’s rights. We identified breaches of regulation related to safe care and treatment and safeguarding service users from abuse. Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question, “Is the service well led?” to at least good.

At this inspection in December 2017 we found significant improvements had been made and the key question, “Is the service well led?” was now rated good. There was a new manager who registered with the Care Quality Commission to manage the service on 11 August 2017. Like registered providers, registered managers are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. People, relatives, staff and external health and social care professionals spoke highly of the registered manager and the positive changes that had been made at Briarcroft in the short time they had been in post.

The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong. They had acknowledged the areas in which the service needed to develop and improve, and, working closely with the local authority quality and improvement team, had been proactive in making this happen.

There were quality assurance systems in place to help assess the safety and quality of the service, and identify any areas which might require improvement. The findings of the audits informed a service improvement plan, with clearly defined actions, responsibilities and timescales. The views of people, their relatives, and staff were actively sought to ensure the service was run in the way they would like it to be.

People told us they felt safe and there were sufficient numbers of staff deployed to meet their needs. Regular health and safety checks were undertaken at the service. There were effective infection prevention processes in place, the home was now compliant with fire regulations and a programme of refurbishment was in progr

Inspection areas



Updated 22 February 2018

The service was safe.

People were protected from risks posed by the environment, which included the spread of infection, because safe practices were in place to minimise any associated risks.

People were protected by staff that understood and managed risk. People were supported to have as much control and independence as possible.

People were protected from avoidable harm and abuse.

People had their medicines managed safely.

People were protected by safe recruitment practices and there were sufficient numbers of skilled and experienced staff to meet people�s needs



Updated 22 February 2018

The service was effective.

People received support from staff that knew them well and had the knowledge and skills to meet their needs.

Staff were well supported and had the opportunity to reflect on practice and training needs.

Staff had a good understanding of the Mental Capacity Act and promoted choice and independence whenever possible.

People�s eating and drinking needs were known and supported.



Updated 22 February 2018

The service was caring.

People and their relatives were positive about the service and the way staff treated the people they supported.

Staff were kind and compassionate and treated people with respect.

Staff supported people to improve their lives by promoting their independence and wellbeing.

People were supported in their decisions and given information and explanations in an accessible format if required.



Updated 22 February 2018

The service was responsive.

People received personalised care and support, which was responsive to their changing needs. Care records were written to reflect people�s individual needs and were regularly reviewed and updated.

People were involved in the planning of their care and their views and wishes were listened to and acted on. People�s end of life preferences were known and followed.

People had opportunities to take part in a range of activities and social events according to their individual interests and preferences. Equality and diversity was respected and people�s individuality supported.

People and their relatives knew how to make a complaint and raise any concerns. People had no concerns.



Updated 22 February 2018

The service was well led.

The management team provided strong leadership and led by example.

Quality assurance systems drove improvement and raised standards of care.

The provider and registered manager had clear visions and values about how they wished the service to be provided and these values were understood and shared by the staff team.

Staff were motivated and inspired to develop and provide quality care. They felt listened to.