Archived: Brookwood Manor

Updated 5 August 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors conducted this site visit.

Service and service type

Brookwood Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Prior to our inspection we reviewed information we held about the service. This included any safeguarding referrals and notifications that had been sent to us. A notification is information about important events which the service is required to send us by law.

The provider had not completed a provider information return (PIR) as we had not requested one. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

As part of planning we sought feedback from other agencies such as the Local Authority and we used this information to plan our inspection.

During the inspection

We spoke with all four people who used the service and observed their experience of the care provided. We spoke with seven members of staff including the outgoing and new manager appointed, care workers and maintenance.

We reviewed a range of records. This included four people’s care records and their medication records. A variety of records relating to the management and maintenance of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two professionals who regularly visit the service. We fed back our findings using ‘Teams’ and put this in writing to the Nominated Individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 5 August 2021

About the service

Brookwood Manor is a country manor which has been adapted into a residential care home. It provides personal care for up to 28 people, aged 65 and over and many of whom live with dementia. At the time of inspection, four people were living in the home.

People’s experience of using this service and what we found

People were not always kept safe. This was because the environment was not entirely suitable for people living with dementia. The four remaining people were accommodated on the ground floor. We identified risks relating to ligatures and plastic bags. The environment was not cleaned in line with the cleaning schedules to prevent COVID-19. The garden was unsafe due to an open broken gate, stagnant water feature and loose bricks.

The wider registered environment on the first and second floor was unfit to accommodate people. It was in a state of disrepair, with some areas questionably un-safe. We asked for a schedule of works that was planned to bring this up to standard, but this had not been developed at the time of our visit.

People still did not have access to a usable shaft lift.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the environment, policies and systems in the service did not support this practice.

There were insufficient staff to support people. Vacancies were not filled. People were supported by a small regular staff team who had completed training to aid them in their role. Staff knew people’s needs well and cared about individual’s wellbeing.

Despite there being no cook meals were well presented and appetising as the interim manager had stepped in to provide a hot meal each day. The latest food hygiene rating was rated level one Major Improvement Necessary.

People did not have access to sufficient sources of meaningful engagement and were at risk of social isolation.

The provider had engaged the services of a consultant. Care plans were improved and care staff were given clear information to support people. Medicine management was generally safe with people getting their medicines as expected.

The service continues to have managers that do not remain long in post and do not register with CQC. This has led to sporadic oversight and inconsistent decision making and action to improve the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was Inadequate (published 15 June 2021).

At this inspection not enough improvement had been made and the provider was still in breach of regulations and remains Inadequate.

Why we inspected

This was a planned inspection based on the previous rating. We needed to ensure people were safe. This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Brookwood Manor on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We have continued to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified ongoing breaches in relation to good governance, staffing, complaints management, safe care and treatment and maintenance of the premises at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will closely monitor this service along with our partner agencies. We will request a specific action plan relating to the environment and ensure the provider meets the terms of their registration. We want to understand what the provider will do to improve the standards of quality and safety. We will return to visit as per our re-inspection programme. If we receive any concerning information we will inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. We have taken action in line with our enforcement procedures. This means we have begun the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration. We have already placed conditions on the providers registration to prevent the admission of people to the service and to ensure the provider adequately assesses and monitors risks to the service.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.