Brenalwood 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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At our last assessment, the service was in breach of legal regulation in relation to safe care and treatment, the ways people’s medicines were managed safely and staffing.At this assessment we have found the provider is no longer in breach of regulation. Improvements made needed to be embedded in practice and sustained. There were some areas which needed further improvement, including medicines and the ways risks were assessed and mitigated, which had not been addressed at the time of our assessment.

This service scored 62 (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 made improvements in their proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Improvements were being made in how lessons were learnt. These improvements needed to be embedded in practice and sustained.

Since our last assessment, the provider had improved the processes for how lessons were learned, which were still being implemented. Incidents and accidents were now being documented, analysed to check for any trends and measures put in place to reduce risks.

Lessons were now being learned, and these were shared with staff in meetings, such as daily flash meetings, handover meetings and staff meetings. These improvements needed to be sustained and continue to be embedded in practice.

There was a duty of candour policy in place, which was being followed when something went wrong, this included updating the person or their representative, where appropriate including an explanation of the event, actions taken to reduce risks and an apology.

There had been no admissions since our last assessment. At our last assessment, the local authority had suspended placing people into the service. Prior to this assessment the provider told us the local authority had lifted the suspension. The provider had made the decision not to accept any new people into the service until we had undertaken an assessment of the service.

The management team told us how they planned to improve the assessment process when people moved into the service. They were planning to accept up to 2 people each month to ensure a safe transition. This had not yet been implemented.

The registered manager told us how they shared information with healthcare professionals should a person need to be admitted, for example into hospital. They told us about a person who had been in hospital and was ready for discharge, a needs assessment was planned to ensure the service could continue to meet the person’s needs and a staff meeting was held where staff were given guidance on the person’s specific needs. This ensured a smooth transition back to the service.

Improvements had been made since our last assessment, which needed to be embedded in practice and sustained. 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 were systems in place designed to reduce the risks of abuse. These included a safeguarding policy and procedure and staff training. Staff’s understanding of their roles and responsibilities was checked by the management team in audits and monitoring of the service and also in targeted staff meetings where staff were reminded of their role and had the opportunity to discuss any concerns. Safeguarding information was posted in the service which gave important telephone numbers and contacts should anyone in the service wish to report safeguarding concerns, including visitors.

Where there were concerns regarding safeguarding, the service had appropriately informed the local authority safeguarding team and formally notified Care Quality Commission (CQC) as required. A log of safeguarding incidents was kept which included if the local authority investigation had substantiated the safeguarding or not and measures put in place to learn lessons and reduce future risks.

Where required, Deprivation of Liberty Safeguards (DoLS) applications had been made, and these were kept under review.

Staff had received training in Mental Capacity Act (MCA) and DoLS and themed staff meetings showed these were discussed to support staff understanding.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had improved and included the risks in people’s daily lives and guidance for staff in how the risks were to be reduced. However, this was not yet fully implemented and embedded in practice. There were still some areas which needed further improvement. For example, a person’s continence assessment stated they did not use continence products which was contradicted in their care plan which said they did. Mitigations for falls for people who did not independently mobilise included the use of appropriate footwear as a way of reducing falls. A person’s care plan stated they used a walking frame to mobilise, however there was a risk assessment in place which referred to the use of a hoist when a hoist was not used. We fed this back to the management team they assured us this would be addressed and the improvements in the risk assessments was ongoing.

There were no people in the service with a pressure injury, and records showed how the risks of these were mitigated. However, a person’s care plan identified they could move position independently, some of the daily notes showed the person was being supported to move position by staff. The registered manager confirmed the person did not need to be repositioned by staff, they told us they would check the notes, and it may be a recording error.

We observed staff supporting people with mobility equipment, this was done safely by staff, with lots of encouragement to the person. We observed a staff member supporting a person who was in wheelchair, when they were passing through a door they said, “Put your arms inside the chair as we are going through the door now.” This demonstrated they had recognised a risk and took action to reduce it.

People and relatives told us they felt the service was safe. A relative told us, “[Family member] is very safe here, staff look out for [family member] and everybody.”

A visiting professional told us, “Their standards were not up to scratch but over the last 4 to 5 months not so many problems, such as pressure sores, residents seem happier, lot calmer, it has definitely improved, that’s positive.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Records showed people were living in an environment which was safe, this was because checks were undertaken to reduce risks, this included fire, electrical and gas safety and legionella checks. In addition, checks and servicing were being completed on equipment used, including mobility equipment. Daily notes demonstrated equipment used, including pressure mats were checked they were working by staff.

The registered manager routinely checked the environment, and any risks were addressed. The registered manager told us the maintenance staff member had recently left, and they were actively recruiting to the role, until this was filled the maintenance staff from another of the provider’s services was on site two days a week.

Staff had received training in health and safety, including fire safety training which was recently delivered by an external organisation face to face.

A business continuity policy and procedure was in place which provided staff with guidance on actions to take in case of an emergency.

Improvements had been made since our last assessment which needed to be embedded in practice and sustained. There were now enough qualified, skilled and experienced staff, who received effective support, supervision and development.

At our last assessment, we found there were insufficient staff to meet people’s needs safely and effectively. This had been a concern at previous inspections with repeated breaches in this area. At this assessment, there were reduced numbers of people living in the service, having 24 vacancies. The service will need to ensure that improvements in staffing would be embedded and sustained, particularly if more people were to be moving into the service. The management team told us they would keep the staffing levels continuously under review, as new people moved in.

There were no agency staff being used, the registered manager told us this had been since March 2025. This was because there were enough permanent staff to support people and ensure consistency. The registered manager told us if an emergency arose, such as short notice leave, existing staff would fill the rota. A relative told us, “Staff are more relaxed with no agency and happier… staff now spend more time with residents rather than telling agency what to do.”

Staff told us they felt there were enough of them to meet people’s needs. This was confirmed by people using the service and relatives. We saw staff were available when people needed them

and staff were present in the shared area to reduce any risks. Staff had time to spend time with people. A relative told us how the service was much calmer and how the staff were attentive to people, “[Staff] used to be running around like headless chickens, it is much calmer now… This is not just for show for you, it is always like this.”

At our previous assessment, there had not been a senior on duty at nights to support people with their medicines, if required. At this assessment we were told there was always a senior on duty throughout the 24 hour period. However, the staff rota, did not show a senior staff at night, the registered manager pointed out the staff members who were seniors on the rota and told us this would be addressed.

Call bell response times were now being monitored by the management team to ensure people were supported when they needed assistance. At the time of our assessment, the majority of people spent their day in the shared areas, which reduced the need for staff to answer call bells in people’s bedrooms. The care home had 2 floors, at the time of the inspection visits, only the ground floor was being used.

At our last inspection we had identified an ongoing concern regarding how staff recruitment was being managed. At this assessment, we reviewed 3 staff recruitment records, which showed the appropriate checks were made, including, Disclosure and Barring Service (DBS) checks which provide information including details about convictions and cautions held on the Police National Computer. This information helped employers make safer recruitment decisions.

Staff were being provided with training to meet people’s needs, this was being monitored to ensure staff were undertaking their on-line required training. The regional manager told us how they had identified staff may benefit from more face to face training, which was being planned. The regional manager told us this training was being tailor made to the service. In addition to the training provided, staff had to opportunity to undertake qualifications relevant to their roles, including the Care Certificate, which is a set of induction standards to be provided to staff. A staff member said, I’ve been appointed Champion for [specific area of care] and have received dedicated training to support this. Over recent months, staff have engaged in a range of regular training sessions, including a full day focused on fire safety and resuscitation procedures.”

Staff were receiving 1 to 1 supervision to provide them with a forum to receive feedback, discuss any concerns and to identify any training needs they had. Meetings had been implemented with new staff during their probation period, to ensure they felt supported and any ongoing learning was identified and addressed.

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. However, we noted 1 staff interaction which did not demonstrate good infection control processes. A person had spilled some of their meal onto the place mat, a staff member scooped the food from the place mat and put it back onto the person’s plate. This was not hygienic.

The service was visibly clean throughout. Staff had access to personal protective equipment (PPE) and this was used as required.

Audits and monitoring systems assisted the management team to identify any issues and address them. People’s care plans included information about any infection control risks and how they were reduced. We saw people’s hands and nails were clean, reducing infection control risks.

There was 1 full time domestic staff member and two part time staff, domestic cover was in place each day. The registered manager told us the domestic staffing levels would be continuously assessed going forward. There was an infection control and prevention policy and procedure in place and staff had received training in this area and their competency checked by the management team.

A recent food hygiene inspection had awarded the service the highest score.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines, including controlled drugs (CDs), were stored safely and securely. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Although people received medicines as prescribed, staff did not always follow instructions for administration as directed. We reviewed medication administration records (MAR) and were able to reconcile people’s medicines supply. MARs had accurate information for staff to administer people’s medicines safely including details of allergies and how they like to take their medicines. We saw evidence of good practice with a multidisciplinary approach for covert administration. However, we saw that staff method of administration for 1 medicine deviated from the administration instructions given by the pharmacist.

Care plans were person centred and condition specific. Staff knew who to contact for advice if they were unsure or needed additional support.People taking high risk medicines such as insulin and anticoagulants, had clear management plans in place and access to specialist support. Body maps were used for patches and emollients, and fire risk assessments were completed for paraffin-based products.

Temperature monitoring of medicines storage, including fridge temperatures, was undertaken daily. However, we were not assured that monitoring was effective. We witnessed the maximum fridge temperatures exceeding 8 degrees on two occasions, and some records appeared to be the same value across several days.

Staff completed medicines audits weekly. We saw evidence that people administering medicines had undergone competency assessment. However, we identified that some of these assessments were being carried out by a staff member who did not have the appropriate qualification to assess others.