We carried out a review of the data available to us about Brookvale House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Brookvale House, you can give feedback on this service.
People’s experience of using this service and what we found
Relatives told us people were safe and happy living at Brookvale House.
Safeguarding and complaints procedures were in place and relatives told us they felt able to complain if they needed to.
Systems were in place to ensure the home was kept clean and extra cleaning had been put in place to protect against the risks of Covid-19.
Staff were positive about the management structure, which included a new manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 19 May 2018).
Why we inspected
We undertook this targeted inspection to follow up on specific risks we had identified about the service, based on our data collection. A decision was made for us to inspect and examine those risks, which were the lack of a registered manager and how safeguarding alerts and complaints were addressed.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.
CQC have introduced targeted inspections to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
We found no evidence during this inspection that people were at risk of harm. Please see the Safe, Effective and Well-Led sections of this full report.
The overall rating for the service has not changed following this targeted inspection and remains good.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our reinspection programmed. If we receive any concerning information we may inspect sooner.
We previously inspected in December 2016. During that inspection we found two breaches of regulations relating to consent and care plans not being updated.
The inspection took place on 3 and 4 April 2018. The inspection was undertaken by one inspector and was unannounced. We found improvements had been made and there was no longer a breach of regulations.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
People were safe at Brookvale House. The provider had policies and procedures designed to protect people from abuse. Risk assessments were in place to reduce risks to people’s health and safety. People’s needs were met by suitable numbers of staff who had been recruited appropriately. People were supported to take their medicines as prescribed. There was a cleaning programme in place to reduce the risk of infection.
People received an effective service. Mental capacity assessments and best interests decisions were completed where necessary. People were supported by staff who were trained appropriately for their role. People were supported to eat and drink enough and were offered choices. People were supported to access healthcare services and ongoing healthcare support when necessary. People benefitted from an environment which met their needs.
Staff developed caring relationships with people. Staff supported people whilst being mindful of their privacy and dignity. People were supported to express their views and be involved in making daily decisions about their care and support.
People received personalised care that was responsive to their needs. People enjoyed a range of activities which were tailored to their needs and choice. People and their relatives had access to the complaints procedure. End of life care, when needed, was kind, gentle and personal.
The service was well-led. The registered manager had a system of audit in place to monitor the quality of service provided. The provider and registered manager promoted a positive culture and staff spoke highly of the home and its management. There was a clear management structure in place which demonstrated good management and leadership. People’s views were sought and taken into account. The registered manager worked in partnership with other agencies and ensured that the service continued to learn and improve.
The inspection took place on 8 and 13 December 2016 and was unannounced.
There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The majority of people at Brookvale House were living with dementia and therefore did not always have capacity to make decisions. Where people had capacity to do so, they signed consent to care forms. However, where people were not considered to have capacity to sign, there were not any records to show that decisions had been made in people’s best interests or that the care and support was provided in their best interests. We recommend the provider researches best practice regarding how to evidence decisions are made in the best interests of people using the service.
People and their families were involved in care planning where possible. However, care plans focussed on physical aspects of people’s care needs and did not include information about their mental and emotional wellbeing or include guidance around supporting people living with dementia. Care plans were reviewed regularly but where some people’s needs had changed the care plan had not been updated.
The provider had policies and procedures in place designed to protect people from abuse and staff had received training. People were protected from avoidable harm through the use of equipment, such as walking frames. Risks were managed so that people were protected and their freedom supported and respected. People’s needs were met by suitable numbers of staff. New staff were only employed after satisfactory checks had been received.
People were supported by staff who had received relevant training to enable them to support people they worked with. New staff completed an induction programme which included information about the service and if staff were new to care, they would undertake the Care Certificate. People were supported to eat and drink as necessary and saw healthcare professionals when they became unwell. People received their medicines as prescribed. People enjoyed a range of activities which met their individual needs.
Staff developed caring relationships with people using the service. People were supported to express their views and be involved in making decisions about their care and support. People were offered choices such as what clothes they would like to wear and what they would like to drink. Staff supported people with personal care whilst being mindful of their dignity.
The provider had a complaints procedure in place and people and/or their relatives knew how to make their views known. The registered manager and provider promoted a positive culture that was open and inclusive. The registered manager was supported by an assistant manager and team of senior staff. There were systems in place to monitor the quality of the service provided.
We identified a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and made a recommendation about the recording of best interests decisions. You can see what action we told the provider to take at the back of the full version of the report.