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We are carrying out a review of quality at Brookwood Manor. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 17 April 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, 22 people were living in the home.

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

We found continued shortfalls in the oversight and governance of the service. The leadership and culture of the home failed to identify significant shortfalls in the management of the service. These failings placed people using the service at risk of harm, and significant exposure to the risk of harm.

The provider continued not to have a registered manager in place. On day one of our visit we found the chair of the company that owned the service had stepped in three days previously as manager. A manager from an agency came for seven days and then was replaced by another manager on a short-term contract.

There was a lack of consistent managerial oversight at the service, which led to risks to people not being identified, acted on or reduced adequately. The provider’s risk management remained ineffective, and did not identify where there were serious risk issues. Therefore, incidents continued to occur and place people at risk of harm.

We were not assured the provider was doing all that was practical to ensure people were protected from the risks of acquiring infections, including COVID-19. The service was not consistently following Government guidance about how to operate safely during the COVID-19 pandemic, this included the wearing of personal protective equipment [PPE], cleaning regimes, social distancing and ensuring staff were provided with designated areas for putting on and taking off their PPE. On both days of our visit we found discarded PPE and used lateral flow tests. Some PPE was readily available to staff, but not masks nor face shields/goggles when required.

Risks to people’s health, welfare and safety continued not to be identified with action taken to reduce the risk of harm. Audits did not identify the shortfalls we found as part of this inspection, and there continued to be a lack of effective quality and safety monitoring in place to drive improvements needed. This included the risks to people in the event of a fire, acquiring infections, legionella risks, risks to people of scalding from exposure to hot water pipes and unguarded radiators, risks of falls and of losing weight.

People had to endure times when the heating had failed or been ineffective since our last visit in December 2020. On day one of our visit most parts of the home were warm. However, exposed radiators and pipes posed a significant scald risk to vulnerable elderly people living with dementia. Even after we fed back these issues, they remained on day two.

The provider did not follow their own policy in the management of people’s medicines when needing to be administered covertly.

Rating at last inspection

The last rating for this service was Inadequate. (Published 12 February 2021).

At our previous inspection in December 2020, we found shortfalls in the management of risk to people’s safety and welfare, staff and governance of the service. The service was rated inadequate and placed in special measures.

We have been monitoring closely and liaising with partner agencies.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in response to concerns received about management of the service, and infection control risks. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do n

Inspection areas

Safe

Inadequate

Updated 17 April 2021

Further information is in the detailed findings below.

Effective

Good

Updated 17 April 2021

Caring

Good

Updated 17 April 2021

Responsive

Good

Updated 17 April 2021

Well-led

Inadequate

Updated 17 April 2021

Further information is in the detailed findings below.