Brook 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 requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations relating to people’s safe care and treatment and staffing. The provider failed to do all that is reasonably practicable to mitigate any such risks around the proper and safe management of medicines. The provider failed to ensure staff received appropriate training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

This service scored 50 (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 proactive and positive culture of safety based on openness and honesty. Staff had not always listened to concerns about safety and did not always investigate and report safety events. Lessons had not always been learnt to continually identify and embed good practice. The training records provided identified gaps in staff training. However, the manager had support from external sources including the local authority and was in the process of retraining all staff using additional training resources including face to face training sessions to equip staff with the skills required to carry out their roles effectively. The manager told us, “Relatives are more aware of how proactive we are now and how we will monitor people using the service and how we look for signs. Staff are not frightened to ask questions anymore. We are improving the learning culture; however, this will take time.” A staff member told us, “We are now included in investigations, we never knew the outcome before, but the new manager tells us the outcome or what happened.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The local authority had placed a suspension on new admissions to the service whilst they work together with the provider and manager to ensure improvements already underway are maintained and embedded. The manager told us, “The usual process would be receiving a referral sent through from a local authority. We would look through the assessment plan and if we felt we could meet the person’s needs arrange for a face-to-face assessment. We would also include and welcome any next of kin/advocate input.” A relative told us, “I visit the

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. People told us they felt safe living at the service. One person told us, “I do like living here, because I feel comfortable.” Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people including informing other agencies if they were concerned about action being taken. Training for staff had been scheduled and was ongoing as previously this had either lapsed or not been planned. The manager had also provided staff with safeguarding information. A staff member told us, “I would look for changes in mood, reactions to other staff, I would look for bruising and report this to the manager. I would report higher if I needed to and report to CQC.” The manager since commencing in post had created a safeguarding overview moving forward to ensure any future safeguarding incidents raised, information would be easily accessible in relation to the allegation, actions taken and outcomes for people. Accident and incidents were documented and since January 2025 these were now captured on the service’s electronic care planning system, however further improvements were required to evidence the service used this information to learn from and prevent similar incidents/accidents occurring in the future.

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. The manager had recently changed people’s care plans over to a new electronic care planning system and had included staff, people and relatives in gathering information to ensure people’s whole holistic care needs were captured. Although individual risks to the majority of people had been assessed we found all people using the service had been placed on fluid charts with no individual daily targets being set. For example, we reviewed a person’s fluid intake from 6 January 2025 to 13 January 2025, their daily intake recorded varied from 55ml to 605ml daily. This was for a person whose care records included a risk of dehydration care plan. We found no oversight of people’s monitoring charts to determine what/if any action needed to be taken when people’s fluid intake was low, although staff we spoke with were able to tell us about people’s care needs and how best to support them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Our walk round of the environment showed it was tired and dated in areas and we found heavily stained flooring in 1 bedroom and the carpet in the downstairs communal lounge appeared worn and stained. We did see some bedrooms had been newly decorated and the manager sent us their improvement plan with a list of proposed works scheduled to be undertaken around the service. This was work in progress. We spoke with the maintenance staff member who told us, “I do regular checks on general maintenance then the staff write in a book for anything else that wants doing. It’s much easier to get things done with the new manager.” People or relatives we spoke with did not raise any concerns regarding the environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision, appraisal and development. At the time of our onsite assessment visit staff had not received supervision or appraisal under the new management team, these were to be scheduled. The last supervisions we saw whose files we reviewed dated back to February 2024 and their appraisals were carried out in August 2022 and July 2023. The provider had long standing agency staff in place to ensure continuity of care for people. The manager and external operations manager were undertaking a staffing restructure to improve staff culture at the service. The manager had implemented a re- training programme to include all statutory subjects to assure themselves of staff skills, knowledge and suitability for their roles. Recruitment processes were underway with several vacancies successfully recruited to. The manager told us, “We want to recruit the right staff, not just anyone, which will take time.” People, relatives and staff did not raise any concerns in relation to staffing levels and from our observations there appeared to be sufficient staffing to attend to people’s needs when required.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading o. The manager told us previously the care staff were responsible for maintaining the cleanliness of the home. This has since changed; a new housekeeper has started with plans to recruit another to improve the cleanliness of the service and minimise risk of infection. Staff had completed infection prevention and control training and had access to personal protective equipment (PPE). However, regular infection control audits had not been routinely undertaken to ensure effective oversight of infection control management within the service. The manager assured us systems were being put into place to ensure regular auditing would be completed with any actions taken moving forward, however these were not in place at the time of our onsite assessment visit.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Although people did not raise any concerns with how their medicines were managed, we found some people did not? always receive their medicines when they needed them as they had not been in stock. These were received into the service on the day of our visit. We found during the night people did not have available to them, medicine for ‘as and when required’ use. For example, pain relief if a person was experiencing a headache or other pain symptoms. The manager told us if needed the night staff would contact them and they would make their way into the service to administer a person’s ‘PRN’ medicine if needed. This current practice was not effective to ensure people were able to receive this type of medicine if needed in a timely way. People who were prescribed ‘as and when required’ (PRN) medicines did not have person-centred PRN protocols in place to inform staff of a person’s presentation/symptoms as guidance on when to offer/administer their PRN medicines. The manager told us they were waiting for the GP to review and agree people’s PRN protocols; however, we were provided with no protocols to evidence they had been completed. The manager’s weekly medicines audits were not effective and failed to identify the concerns we found on the day of our onsite assessment visit. After our assessment visit the manager advised new medicines lead champion had been recruited with their main responsibility being to oversee all aspects of medicines management at the service.