Brook House Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 88 (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 had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Safety within the service involved everyone, creating an embedded culture of shared responsibility and continuous learning, enabling a culture of safety and learning. People and their family members told us they felt safe and expressed confidence in raising safety concerns. A person told us, “I’m very safe, there’s nothing to feel unsafe about, I’m well cared for.” A family member said, “I’ve not had any concerns, they are happy to answer any questions I have.”

The provider had a robust system to promote a positive learning culture, ensuring lessons were learned from accidents, incidents, near misses, concerns or complaints. Each event was reviewed and investigated in depth to identify what happened and what actions could be implemented to reduce the likelihood of recurrence. Learning from events was shared consistently and effectively through staff handovers, team meetings, supervision and policy updates, and where required competency assessments of staff. This ensured improvements were not only implemented but sustained and fully integrated into everyday practice across the service. For example, a root cause analysis was undertaken following a recent incident where a person sustained a minor injury after being provided with a hot drink. This identified a more robust and person-centred approach to hot drink safety was required for people who may lack insight or capacity in understanding the potential risk. Several actions were identified, which included the development of a ‘hot drinks safety policy’, the implementation of temperature monitoring procedures, and the provision of guidance and training for staff.

Comprehensive assessments were undertaken for all those residing at Brook House Care Home, which considered people’s wishes and their capacity to understand and weigh the risk associated with consuming hot drinks. Where risks were identified, systems for controlling and monitoring the temperature of hot drinks was introduced for people and audited for compliance. For those people not assessed as being at risk, staff were required to verbally inform them that the drink is hot. In addition, signage had been displayed adjacent to the coffee machines used by visitors and relatives, advising that hot drinks may present a burn risk and encouraging caution when preparing and carrying beverages.

Staff told us there were systems in place to record accident and incidents. All staff we spoke with told us they record information on the handsets provided PCS (electronic care record system). One staff said, “When an incident or accident occurs, people are checked over for injuries, and observations take place. Depending on the injury, we take medical advice if required and record the information on the system. If a person has a head injury, we always escalate as a medical emergency right away. We record all details on the handsets, monitor the person, photograph the injury and complete a body map. All incidents and accidents are followed through from beginning to end by seniors and management. If necessary, district nurses get is involved to advise how we should care for the wound. Another staff said, “Incidents are investigated and staff receive briefings in handover meetings. They also said, “The communication here is excellent. There is a communication book that you have to read daily.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and their families played an active role in shaping how their move into the service was planned and supported, ensuring each transition reflected what mattered most to them and resulted in consistently smooth, positive experiences.

Safety and continuity of care was facilitated by a collaborative, joined up approach to safety, which involved the person, their family members and any professionals involved in their care. A key aspect of the provider’s strategy in facilitating a positive experience for people transferring to the service was the recognition of the importance of a stable and well-trained workforce. Several staff had worked at the service for many years, and lived and worked locally, which contributed to the friendly environment. Many people commented upon this as one of the reasons for choosing to move to the service. A family member told us, “We looked around a few homes and chose it, it’s nice and my relative is happy. The best description is it’s a family environment with very friendly staff, a homely community.”

People and their family members told us their move to the service was planned and based on their decision that Brook House Care Home was where they wanted to move to. Several people told us the service had been recommended to them by people they knew. A person told us, “I came here from hospital I knew about it from a friend. It was the right choice, they are extremely good, I’ve got no criticism at all, they are kind and caring.” A family member said, “The registered manager managed the transition. They came to my relative’s home first to make sure they were suitable and happy to come.” Another family member said, “My relative has been here nearly 3 years. We chose it, we looked at two others, we preferred this one. I think it was a great choice.”

The registered manager informed us that referrals to the service were reviewed and included a face-to-face assessment undertaken by the registered manager in the person’s current residence, including their own home or hospital. Spending time with the person allowed them to gain an insight into the person’s needs, expectations, preferences and aspirations. As part of the assessment the registered manager met with family members, advocates, nursing staff and social care staff or other professionals involved to plan the transfer to the service.

The registered manager recognised that moving into a care home was a significant life event, and that some people required additional support to settle into their new surroundings. The service supported this by operating a 4-week settling in period, where the person’s wellbeing, their adjustment and overall experience was monitored, and where difficulties were experienced, then advice was sought from family and external professionals, to support a successful placement.

When people moved into the service staff said they received updated information on that person through team meetings, shift handovers, and the PCS (electronic care record system) was updated. One staff said, “When a person moves into the service, we get enough information to care for that person. The communication book is updated; an assessment of needs is completed. Care Plans created for all staff to read to correctly meet person's needs”.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There was a strong understanding of safeguarding and how to take appropriate action, underpinned by safe systems, processes and practices to make sure people were protected from abuse and neglect.

People and their family members said they were confident to raise concerns, and that they felt safe at the service. A person told us, “I’m quite safe, there’s plenty of people here for a start.” A family member told us, “I’m very confident that my relative is safe there.” Another family member told us, “I haven’t had any safety concerns.”

Safeguarding concerns had been raised with the appropriate local authority safeguarding team, to promote people’s well-being and protect them from abuse.

The registered manager advised in response to safeguarding investigations any lessons learned and opportunities for improvement were identified, and any learning outcomes shared with the staff team.

Safeguarding was regularly discussed at staff meetings, handover and supervision, providing an opportunity to reinforce staff’s responsibility in reporting concerns and provide a forum for staff to share any information of concern. The registered manager operated an open-door policy, to support both visitors and staff to raise concerns, and seek advice without fear of judgement of repercussion. CCTV was installed within communal areas of the service, which provided an additional tool to support any investigations, and could be accessed by the managing director and registered manager when they were away from the service.

All staff were very knowledgeable in how to keep people safe from abuse, what constituted as abuse and what they should look for. One staff said, “I would also discuss with my peers and management if I had a concern about someone.”

Staff said they had received face to face safeguarding training. One staff said, “I have completed a lot of training since I have been at Brook house. Staff confirmed the training they received was very good and supported them to keep people safe.

The registered manager and management team had a clear understanding of Deprivation of Liberty Safeguards (DoLS), which were only used when it was in the best interest of the person and in line with the Mental Capacity Act 2005.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People and their families were supported and encouraged to understand potential risk. A proportional, and person-centred approach was taken to the mitigation of risk, maximising opportunities for people to maintain their independence and live an active and fulfilling life in line with their wish’s, personal goals and aspirations. For example, where a person wished to walk to the local shop, staff worked with them to identify any risks and implement tailored measures to support this safely. Factors considered included the best route, the person’s physical and cognitive abilities, and considerations as to what, if any support was required. This demonstrated a service that embraced positive risk taking and supported people to achieve what was important to them. A further example was staff facilitating a person to paraglide, working with the family to assess and mitigate risk, enabling them to achieve their personal goal. Following the event, the person wrote an account of their experience for the newsletter, which recorded. ‘Before going on the actual glide, I was very apprehensive about what was in store for me. Having good support from family and everyone from Brook House really helped ease my nerves. It was over much too quickly. I would definitely do it again in heartbeat.’

Family members were aware of how potential risk was mitigated using equipment which detects movement, alerting staff to enable them to respond. A family member said, “My relative has a sensor by the bed, if they get up the alarm goes off.” Equipment was used in a variety of ways to mitigate risk, which included sensors alerting staff when people got up from a chair or bed, or when a person crossed the threshold of a bedroom door, or the door was opened. Timely referrals were made to external professionals when additional guidance or equipment was required to support and promote people’s safety.

People’s care records provided clear guidance as to how identified risks were to be mitigated and were regularly reviewed. These focused on all aspects of people’s lives, including personal care, eating and drinking, and social events and activities. All were tailored to the individual and personalised in line with their goals and aspirations.

Risks were managed in line with people’s care needs and were reflective of a person’s capacity to make informed decisions relating to risks. One staff member gave an example of a person, who required the use of bed rails when they returned from hospital, as they now spent most of the time in bed. The person lacked capacity to consent. Staff said, “DoLS was put in place for the use of bedrails, because of the restriction for their movement, as the person was at risk of falling from the bed.”

Staff were knowledgeable and had access to people’s care records via hand-held devices which enabled them to provide safe care in line with their wishes and assessed needs. A member of staff told us, “People receive all person-centred care tailored to their needs. The care plans are in-depth to ensure all information is there and relates to the person and reflects their needs. We review care plans monthly or when changes occur.”

Staff were knowledgeable of the fire evacuation process. We discussed what staff should do in case of fire. They all said, “Fire wardens are in place and take control of the evacuation process. We asked if PEEPS (Personal Emergency Evacuation Plans) were accessible and staff told us where they were kept and that they were easily accessible in case of fire. We also checked with the night staff who completed the fire test process without the alarm, so people did not become distressed.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment in which people resided was planned and adapted to meet their diverse needs. The facilities, equipment and technology were well-maintained and supported staff to deliver safe and effective care. The environment was understood by the management team to be a key part of providing a good quality service. Environmental improvements were guided by best‑practice dementia design principles and feedback from people, resulting in a setting that not only met safety needs but actively enriched people’s daily lives.

People and their family members described the service as homely and friendly, with people’s rooms being personalised with items they had brought with them when they moved in. A person told us, “It’s lovely here and comfortable.” A family member said, “It’s very homely and has a nice feeling.”

Improvements to the environment were planned and implemented. For example, a lounge had recently been fully refurbished, which included décor, soft furnishings and furniture. Similar improvements had been scheduled for other communal lounges and corridors. The service had a hairdressing salon, however, a new salon had been planned, to enhance people’s experience, of going out and visiting a hair salon, through its design and facilities. Bedrooms were spacious, well-maintained and personalised. Lighting was seen as a key part of the service, with lighting being activated in response to people’s movements, supporting people’s safety. There was clear signage throughout the service, supporting people to navigate independently.

Investment was also evident in outdoor spaces. The well-maintained garden had been designed with consideration to people living with dementia. The landscaped garden incorporated features with clear and accessible pathways leading to areas of interest, such as colour co-ordinated flower beds, seating areas and the recently installed ‘tearoom’. The ‘tearoom’ was an indoor café area, which provided tea and coffee facilities, tables and chairs, and was used by visitors and people as a space to meet up in a social setting. A central courtyard was the other external space which people could access, which provided a seating area and access to other areas of interest, for example the pet rabbits accommodation. A scheduled plan was in place to improve the courtyard area, by introducing new flooring, gazebo, planting and lighting to create a ‘mediterranean’ feel.

The service had CCTV installed, and the provider had followed the guidance provided by the Care Quality Commission to ensure people’s human rights were considered. The service was registered and had a license with the Information Commissioner’s Office and had a data protection impact assessment. CCTV was used in communal areas, which streamed live footage to the office. The registered manager and managing director could also view live footage when away from the service. Signage throughout the service, and information on the electronic ‘sign in and out’ system for visitors, alerted people to the use of CCTV and recording.

Systems, including electrical and fire were maintained, and equipment used to support in the delivery of care, such as hoists was regularly checked for safety. Fire risks were assessed, and staff completed fire safety training.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Robust safe‑recruitment procedures ensured only suitable staff were employed. Staff were supported by an ongoing programme of training, based on recognised standards of care. Professional development of staff was a key enabler in both the retention of staff, and the delivery of safe and high-quality care. In addition to vocational qualifications in care, senior staff were encouraged to undertake the Care Home Assistant Practitioner Programme. This provides additional competence-based training, providing staff with greater knowledge in the monitoring and assessing people’s health, including clinical tasks and care plan development.

There was a commitment that training for staff was reflective of people’s health and wellbeing, to enable staff to respond to people’s changing needs through keeping up to date with changes in best practice guidance, and in response to learning from incidents. This was facilitated through group learning opportunities, to encourage discussions amongst the staff team, and regular supervision, providing staff with dedicated time to reflect on practice, discuss challenges and identify areas for improvement.

The provider and registered manager had invested in dementia training. Training was facilitated by an external organisation, that delivered an immersive experience simulating what it is like to live with dementia, via a visiting ‘dementia bus’. Family members were also invited to join in the experience.

Staff told us the training they received was “Really good” One staff member said, “I feel confident to do my job well.” Another staff member told us they had competed the Oliver McGowan training and gave positive feedback. (It is a legal requirement for all services to ensure staff receive training in learning disability and autism). Staff also told us about the in-house dementia training where staff were a resident for the day. This meant they experienced the restrictions and challenges a person with dementia may experience. The staff said this was excellent training. This demonstrated the registered manager’s strong commitment to building a skilled, confident and motivated workforce. By investing in high‑quality training and structured development, staff were well‑prepared for their roles and felt valued from outset. This contributed to a positive culture, high staff retention and consistently safe, compassionate care for people using the service.

There was a commitment that staffing numbers facilitated a service which was well-managed, with staff having access to managerial support. Staffing numbers facilitated a person-centred approach to care, which considered people’s physical, emotional and psychological needs, both during the day and night, and enabled staff to respond to events within the service.

People and their family members expressed confidence in staff’s ability to meet their needs and told us staff responded promptly to requests for assistance. A person told us, “There’s a call bell in my room, they [staff] always respond quickly.” A family member said, “I would say the staff are very good, they know what they are doing. They always respond to anything quickly.”

There was always a member of the management team on duty throughout the day, 7 days a week, with a deputy manager being on duty at the weekend. Staff had delegated roles to ensure the smooth day to day running of the service. For example, there were always 2 senior care staff on duty throughout the day, 1 being responsible for medicine management and responding to health-related matters, whilst the other senior co-ordinated the care staff team. At night, there were 4 staff on duty, of which at least 2 were senior care staff. People and family members were positive about staffing levels at the service. A family member told us, “Definitely no worries about staff levels. I had to visit at night once, and I was impressed with the number of staff there at 2:00am.” Another family member said, “I visit regularly, there’s always enough staff, they [staff] are always visible.”

To facilitate a person-centred approach to care, additional staff were employed to support people to engage in activities, hobbies and interests both within the service and the community, facilitated by a team of activity staff and supported by flexible staffing numbers. The service employed a dedicated team of housekeepers and catering staff, who worked 7 days a week, and a maintenance team, working 6 days a week, and who were on-call on Sundays.

Staff told us there were sufficient staff at the service and that management accommodated additional staffing when needed. Staff told us the registered manager ensured there were sufficient staff on each shift. A member of the night staff told us where people’s needs changed, and they required another member of staff, the management team had increased staffing numbers from 4 to 5, demonstrating the importance placed by the management team on promoting people’s quality of care and safety.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

An effective approach to assessing, monitoring and managing the risk of infection was in place, in line with national guidance. A daily walk around of the service as undertaken by a member of the management team and documented, with any actions noted being addressed. Monthly infection prevention and control (IPC) audits were completed, which incorporated checking mattresses and pressure cushions to ensure they were clean, intact and suitable for use. We found the mattresses and pressure cushions to be clean and well-maintained.

Measures were in place to reduce cross contamination. For example, each person who required a sling to be used with a hoist, or a sliding sheet to support safe handling when moving them, had their own individually allocated equipment, and was documented in their care plan. Manual handling equipment was cleaned after every use.

Housekeeping staff had delegated schedules of cleaning to complete, which detailed the cleaning method, the frequency and expected standards. Cleaning tasks were recorded once completed. Tasks included a structured carpet cleaning programme, and a steaming schedule for curtains and soft furnishings.

Staff within the service had clear roles and responsibilities in infection prevention and control, which included 2 infection prevention and control (IPC) champions. An IPC champion spoke of what their role entailed and the impact it had on people and staff, they told us they were responsible for ensuring staff followed the provider’s IPC policy and procedure. They said, “If I notice staff breaching the (providers) IPC policy I will intervene.” They spoke of the importance of IPC, stating, “In some cases, it could be lifesaving.”

Staff training records confirmed staff had completed IPC training, and our observations found staff wore personal protective equipment (PPE), including gloves and aprons where required. Staff’s competency in IPC was regularly assessed and documented by an IPC champion.

Potential risks linked to people’s needs were assessed and where required care plans were developed detailing potential IPC risks and the role of staff in managing the risk and delivering safe and good quality care. For example, the importance of good catheter care in reducing the risk of infection.

The service attained an overall score of 99% in March 2026, following an infection prevention and control audit, which focused on environmental cleanliness, IPC practice, and governance, carried out by an independent organisation.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicine was appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance and in line with the Mental Capacity Act (MCA) 2005. A person told us, “I have my medicine twice a day, no problems with it, I get it when I need it. Staff always wait while I take it.”

An electronic medicine management system was used by the service to record medicine administration, instruction and guidance. The registered manager stated this had streamlined medicine management, and enhanced oversight and reduced potential human error. Systems, processes and responsibilities for ordering, collecting, and returning unused medicines were clearly documented.

The provider had robust medicines systems and processes. Care plans gave staff detailed guidance on the support required. This included information about each prescribed medicine, how and when it should be administered, and what the medicine was for. Possible side effects were clearly recorded, along with the actions staff should take if concerns were identified.

Staff responsible for medicines undertook training and had their competency regularly assessed. Staff were knowledgeable about safe systems of medicine administration and were aware of people who had their medicine administered covertly. A member of staff said, “Authorisations are in place for how the medicine should be taken and what with.”

People’s rights were protected and their wishes upheld where they declined not to take their medicine. In some circumstances a Mental capacity assessment, and best interest meeting and decision were made in line with the MCA 2025 where it was identified a person did not have capacity to make an informed decision as to the potential impact on themselves in declining their medicine. In these circumstances, a health care professional and others had identified it was in the best interests of the person to have their medicine given covertly (disguised in food or drink without their knowledge). Clear guidance was provided, signed by a health care professional, detailing how the medicine was to be disguised and administered, and the decision kept under review.

Protocols were in place for medicines which were prescribed for use as a PRN, ‘as and when needed’. For example, to manage pain or support people during periods of distress and agitation. People’s response to the medicine being given was documented, which enabled staff to provide information to health care staff who prescribed the medicine as to its effectiveness, as part of a medicine review.

A system of medicine audits was completed by the management team, including monthly audits and spot checks. Audits focused on medicine administration records, storage, controlled drugs, PRN protocols and management practices. The supplying pharmacy also carried out independent audits.