Brook 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 good. At this assessment the rating has changed to requires Improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance at the service. The provider failed to ensure accurate, complete and contemporaneous medicine records. The providers auditing systems and processes used to assess, monitor and mitigate risks for people failed to effectively identify concerns we found on the day of our onsite assessment visit.

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 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. The manager, management team and provider told us moving forward they were committed to improving the culture of the service. They were keen to encourage and equip staff with the necessary support and skills to know, and understand the vision, values and strategic goals of the provider and were in the process of supporting staff in understanding how their role helped achieve them. The manager told us, “I want to ensure staff are happy, maintaining their wellbeing both mentally and physically as they are the ones looking after people keeping them safe. We are undergoing extensive training, reinforcing values with staff, breaking the old staff culture.” Staff told us they were happier working at the service now, a staff member told us, “The management are so much better, now we are getting things for people as soon as they need it.”

The provider had identified shortfalls in the service and took action to recruit a new leadership team. However, more work was needed to monitor the leadership to ensure they had the appropriate skills to lead effectively. Whilst we saw the leadership team were very supportive to people who used the service and staff, some improvements were required to ensure all aspects of the service were being effectively monitored and robust systems and processes embedded into the service.

Staff and people had not always felt they could speak up and their voice would be heard. Staff told us they now felt the culture of service was changing for the better and felt able to speak up if they had any concerns. Comments included, “I feel I can go to manager with any problems, and they will listen,” and “Staff are much happier now, we were scared to say anything before but now we are more confident.” People and relatives told us, “The new manager is nice,” and “I have met the new manager, and I would say they are very approachable.” Staff had access to the Whistleblowing policy located an App which they sign to say they have read and understood. The manager told us Whistleblowing training is being arranged for all staff.

The provider had not always valued diversity in their workforce. They had not always worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The manager told us, “I am slowly changing the old staff culture, what happened previously we don’t do anymore. Everyone is treated as an equal, people have their preferred choice of staff gender to support them, all staff are offered the same opportunities, have the same access to training. Staff want the home to succeed, so by imparting and sharing our knowledge with the staff they feel more confident.” Staff spoke positively about the changes, a member of staff told us, “I feel I work as part of a team here and I feel it is getting much better.” Staff had access to the service’s equality and diversity policy and procedures via an App, which they then signed to say they have read and understood. Whilst staff told us the leadership team were supportive there was still some improvements required to ensure all staff received equality and diversity training. The lack of regular supervision and appraisal for staff may not have always provided an opportunity for staff’s individual and diverse needs to be identified or considered.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. At the time of our assessment the service did not have registered manager in post. However, the manager was in the process of applying to register with the Care Quality Commission. Staff spoke positively about the new manager and the majority felt supported by the manager. Comments included, “I have seen some changes since the new manager started here, for the better,” and “The new manager has made some really good changes here and is very good and approachable.” However, we found the providers systems and processes used to monitor the quality and safety of the service required further improvement to ensure all areas of the service were monitored effectively ensuring robust oversight was in place. This was in relation to the safe management of medicines, staff supervision and appraisal, auditing processes for infection prevention control, health and safety and effective oversight of monitoring forms in place for people. We were not assured there was effective oversight in these areas.

The provider had not always understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They had not always shared information and learning with partners or collaborate for improvement. The manager with the support of an external operations manager had been working closely with local authorities, attending strategy meetings and working through a plan of identified actions to improve outcomes for people. We received positive feedback from a professional who told us, “The service engages in various meetings organised to share learning and improve outcomes. These engagements help the service stay updated on best practices and implement necessary changes.”

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They had not always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. However, significant improvements were being undertaken within the service, with a focus on improving the environment, upgrading software systems and investment in staff training and recruitment which was ongoing.