Brenalwood Care Home

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 inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. At our last assessment, we found the service was in breach of legal regulation in relation to governance at the service. At this assessment we have found the provider is no longer in breach of regulation. Improvements needed to be embedded in practice and sustained. We identified some issues which had not been addressed at the time of our assessment. We were assured by the management team these improvements were ongoing, and further work was being done.

This service scored 64 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Since our last assessment improvements had been made in the culture of the service. Staff were able to explain how improvements had been made and how they felt this had impacted on the care people received. A staff member said, “[Registered manager] has fostered a culture of collaboration and open communication among the staff, which has resulted in marked improvements in many areas.” Another staff member said, “We also hold regular meetings to discuss residents’ care needs and staff supervision, which helps us maintain high standards of support and teamwork within the home.” A third staff member told us, “Brenalwood is more than just a workplace, it's a community where every resident is treated with dignity and respect, and every staff member is empowered to make a positive impact.”

Staff received information on the requirements of their role and the systems in place to meet people’s needs in training, policies and procedures and meetings including staff meetings, daily flash meetings, handover and one to one supervision meetings. Staff meeting minutes from September 2025 demonstrated staff received guidance to ensure they were respecting people’s diverse needs and to listen to their choices regarding the care they received.

Since our last assessment staff roles as ‘champions’ had been developed, for example, named staff were oral health champion, and safeguarding champion. We reviewed the training records and saw that, for example, the safeguarding champion had received enhanced training.

Systems were in place to share learning and good practice across the provider’s locations, including information sharing and meetings with regional and registered managers.

Since our last assessment, changes to the management team had been made. The provider now had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

At our last assessment we were concerned that there was a lack of stable management in the service. In addition, previous inspections identified concerns with the governance of the service. The provider had failed to ensure previous improvements were sustained. At this assessment further changes in management had been made. This included the direct management of the service and the provider’s governance systems and staff. There was a new registered manager in post who had started working in the service in December 2024, registered in March 2025 and a new deputy manager.

We received positive feedback about how the registered manager and deputy manager had implemented improvements. The registered manager told us they had been registered to undertake a levels 5 qualification relevant to their role, the deputy manager had also been signed up for this qualification. A staff member told us, “The manager is good to us, communicated to us. [Registered manager] communicates with the residents and spend time with them.” Another staff member said, “Our manager has been a great source of guidance and support to all staff members, ensuring that we provide the best possible care for our residents. Under their leadership, the team feels well-supported and motivated in our roles.”

The provider’s senior management team had been expanded, with additional regional management and compliance oversight.

During our inspection we spoke with the registered manager, compliance manager, regional manager and 2 directors. All spoke with us about how improvements had been made in the care provision and oversight, to support the provider to monitor the service and take action when required.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There was information posted in the service to remind staff how they could speak up if they were concerned about anything in the service. The provider had freedom to speak up champions who could provide staff with support. Staff told us they understood the whistleblowing procedure and would report concerns if required. The management team told us how staff were empowered to raise concerns to the registered manager and the provider’s senior leaders if they chose to. A staff member told us. “The atmosphere is calmer, we are listened to, have flash meetings, can bring things up and they are dealt with, the manager’s door is always open.”

Satisfaction surveys completed by people using the service, their representatives and staff were analysed and actions planned to improve, where required. For example, in the staff survey completed May 2025, it stated they would continue with momentum in making improvements and maintain team meetings, open communication and lessons learned.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us there was a diverse workforce who worked well together as a team, based of respect for each other and backgrounds. This was confirmed by staff. A staff member told us, “The atmosphere among the staff has also improved greatly. Everyone works together like a family, helping each other and supporting one another. A lot of these positive changes have come under the leadership of our new manager, who has made a huge difference to the home. The care home now runs smoothly, and both residents and staff are happier and more positive.”

The nominated individual told us staff were empowered to raise concerns and make suggestions about the service, not only to the registered manager but also to senior leaders within the organisation.

At our last assessment, and previous inspections, we had noted shortfalls in governance, this included a failure to make and sustain improvements. Since our last assessment improvements had been made. The provider now had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care. These improvements needed to be embedded in practice and sustained.

The regional manager explained the new systems in place and told us how they supported the service in the ongoing improvements, including attending the service to do audits and monitoring. This included systems linked with the key questions safe, effective, caring, responsive and well-led. Where shortfalls were identified, support was given to the staff and registered manager to implement improvements. As part of the monitoring the regional manager also spoke with staff, people sign the service, their representatives and external professionals. We saw records which confirmed what we had been told. The provider’s compliance team were kept updated and also monitored the service provided.

The registered manager undertook a range of audits. Manager walk around audits had improved, they demonstrated what the registered manager had reviewed and where shortfalls had been addressed, for example, cleaning the dining room tables.

However, we identified some shortfalls which had not been either identified or addressed by the governance systems in place. This included in care plans, daily notes, how staff recorded if consent was given when providing care, medicines, the previous manager’s name being on a risk assessment and reference to another care home in the service user guide. The majority of these were addressed immediately once we pointed it out, and the management team assured us the governance processes were ongoing.

Since our last assessment, improvements were being made, however, this was ongoing and not yet fully implemented. The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager told us how they were working to access services in the community, this included individual from a local place of worship visiting the home monthly, and working with a local hospice, who the registered manager told us they were planning to take them up on their offer of providing staff with face to face end of life training. The registered manager told us they were looking at what additional support they could provide to access the community both inside the service and externally.

The management team told us how they had worked with social care professionals to implement improvements. This was confirmed by social care professionals who provided the improvement plan being worked on by the service which was monitored by the local authority. The local authority had ceased placing people in the service until improvements were made. Prior to our assessment we were told improvements were noted and the provider was able to take in new people. The management team told us they had made the decision to wait until our assessment was completed until new people were admitted into the service. The management team told us how they were planning to maintain and make further improvements, including when external professionals withdrew.

At our last assessment and previous inspections, we had identified repeated concerns relating to governance. This included the failure of the provider to learn lessons and to sustain improvements made. During this assessment we identified ongoing improvements were being made but these needed to be embedded in practice and sustained. The provider had focused on improvement across the organisation and local system.

The registered manager told us how they kept updated by reading published inspection reports to learn from these and implement changes in the service. They also told us how they had used the enforcement notice served at our last assessment and report to make improvements in the service provision.

A service improvement plan was in place which identified plans for further and continuous improvement. The provider told us how they had improved the garden in the better weather so it could be enjoyed, and the next steps were to look at redecoration in the internal shared areas.

Staff were provided with training relevant to their role, the regional manager told us improvements would be made with more bespoke face to face training was planned to be provided as well as eLearning. Targeted themed staff meetings were held in subjects such as safeguarding and Mental Capacity Act, where staff discussed their understanding and were provided with updates by the registered manager. We saw records which showed the service were taking up the offers of external professionals in attending workshops and training, this included from the Occupational Therapy (OT) team.

We received feedback from people using the service, relatives and staff which reflected the improvements we had found during this assessment. One relative said, “It is amazing, I love it, it was not amazing, but the turnaround has been amazing, had no regular manager then, did not get informed of situations… 100% turnaround since last inspection, definitely in the place it needs to be, I now leave feeling happy.”

A staff member said, “I have seen a huge difference in the care home, especially over the last seven to eight months. After the challenges we faced last year, we have worked hard as a team to improve the home in every way.”