Brooklands Homecare Ltd

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 that 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 question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service and the lack of day-to-day oversight provided by the registered manager.

This service scored 36 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. For example, by not ensuring staff received training and guidance to understand the challenges of the people they supported. People were asked to complete feedback surveys about the service and the support they received on an annual basis. However, the 2024 survey had not been circulated. At the time of our inspection visit, the branch manager had not analysed the 2025 survey results which had been returned in April. We reviewed the replies and there had been no documented responses to address those with lower scores. Later during our inspection, the registered manager and branch manager separately emailed explanations about the lower scores, along with an analysis. Although there were limited opportunities for people to feedback, they and their relatives told us they could contact the management when needed to discuss their support. We reviewed compliment cards from people and their relatives; the branch manager told us they shared compliments with staff at meetings.

Leaders did not understand the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge and experience to lead effectively. Although the service was run by a compassionate branch manager; the registered manager did not hold day to day oversight of the service. The branch manager told us they could contact the registered manager when needed. During our inspection it became apparent the branch manager did not hold knowledge of our Regulations and legislation despite being delegated this responsibility by the registered manager. A mental capacity assessment was completed incorrectly, correction fluid was used to change an outcome and the documented evidence contradicted the outcome, this had not been identified by managers. The branch manager did not have a working understanding of the duty of candour and when it would be appropriate to notify CQC of events within the service. However, the branch manager was highly thought of by people, staff and professionals. Some comments included, “I reach out to them as [branch manager] is lovely, I am not micromanaged.” And, “I have had dealings with [branch manager], they always listen and communicate when things need to be told.”

The provider’s processes did not support a culture where people and staff could speak up and their voice would be heard. The provider’s whistle-blowing policy was overdue review in May 2024 and did not contain full details to signpost staff if they needed to speak up outside of the service. During our feedback meeting, the branch manager told us due to their friendships, staff would not contact external agencies if they needed to speak up and would only go to them or the registered manager. This posed a risk of a closed culture. Regular staff supervisions did not take place, they were formally invited to an annual appraisal and were observed once a year, staff meetings took place annually. We reviewed minutes of the staff meeting for 2024 and did not see staff were invited to speak up and participate. The staff minutes of 2023 included staff requests for some training to be face to face; 1 was yet to be arranged.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff were not invited to formal supervision to discuss their ongoing development. There were delays in some staff’s annual appraisals including 2 staff who had not had an appraisal since December 2023. Staff told us they felt listened to and were respected. Comments included, “I feel so valued there and I only do [number] hours.” And, “Yes, I get well supported and my work pattern works for me at this time.” The branch manager gave an example of how they engaged with staff to support them when going through personal issues. Although there was a lack of formal staff supervision, the branch manager told us staff contacted them frequently and staff confirmed this. A staff member told us, “I get phone calls regularly to see how I am; they are very supportive. I really enjoy working here.” Another said, “In our meetings or individual conversations with management or on-call I would express my views and opinions.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not identify information about risk, performance and outcomes. Quality assurance processes were not carried out by managers to assess the safety and performance of the service. There were no audits completed to ensure people’s health conditions were risk assessed, and care records were complete and up to date. Other areas of safety were not monitored including infection prevention and control. There were no checks to ensure medicines were being managed safely and in line with national guidance besides audits on MAR charts which were designed to identify gaps in staff record keeping. We reviewed the MAR chart audits which concluded no gaps were apparent, but when these were compared to the MAR charts we found gaps. This meant the audits were not effective. The management team did not conduct any spot checks or supervisions besides annual observations with staff to ensure people were receiving safe and appropriate support. The branch manager told us the registered manager and quality lead from head office visited the service each year and conducted some quality assurance checks. However, they and the registered manager were unable to provide evidence of this and any outcomes from the visits.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Whilst the service shared information with partners and collaborated for improvement, they did not update people’s care records with their outcomes. We reviewed multiple examples of where staff and managers had worked well in partnership with professionals to improve people’s outcomes. This included where equipment was needed, changes to allocated support times and contact with district nurses, OTs, audiologists and GPs. Although advice had been sought it had not been updated and included in people’s information sheets to reflect people’s needs. Health and social care professionals provided positive feedback about how they worked with the service. A social care professional said, “If we call [branch manager] they are always responsive and keen to work with us and adjust care, where a patient has specific needs for care package, [branch manager] is willing to listen and see what they can do the make care package fit the person.” The branch manager updated staff through emails and Whatsapp. However, using this method meant people’s confidential information was broadcasted to the whole staffing team including those who did not support some individuals and the method was not secure.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. The registered manager did not ensure the branch manager received adequate training to keep their knowledge up to date for continual learning. The provider’s policies had not been updated and were not easily accessible to staff, some policies were incomplete, and some policies were not being followed. Out of date forms were in use, such as the application form which meant staff were agreeing to Criminal Record Bureau checks instead of Disclosure and Barring checks. Application forms did not request a full employment history including gaps to ensure people were being supported by appropriate staff and in line with our Regulations. There was no learning taken forward from a previous inspection at the provider’s other service in relation to ensuring recruitment practices were safe and the need for comprehensive audits of care records and care calls to be completed.