Brockenhurst

“The inspection was prompted in part by notification of one incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of this incident. We also inspected to follow up on the breaches of regulation found at the previous inspection in March 2025.”

“The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of this regulation. The provider was previously in breach of the legal regulation in relation to person-centred care and good governance. Some improvements were found in these areas at this inspection, but the provider remained in breach of these regulations. The provider was previously in breach of the legal regulation in relation to staffing. Improvements were found at this assessment, and the provider was no longer in breach of this regulation. Following the last inspection, CQC imposed conditions on the providers registration to drive specific improvements, mitigate risks, and closely monitor those standards that had fallen below required standards.”

“Brockenhurst has made progress since the previous inspection; however, several areas still required improvement to ensure people consistently receive safe, effective and person‑centred care.”

“There continued to be variability in the quality and consistency of staff practice, particularly in relation to dignity, engagement and the promotion of choice. Observations highlighted that people did not always experience respectful or person‑centred interactions, with some staff not recognising or responding appropriately to people’s verbal and non‑verbal cues during mealtimes or personal care. Staffing levels and deployment were not always sufficient to ensure people received timely support or meaningful engagement, especially on the first floor where limited staff presence resulted in long periods without stimulation. Staff supervision and training, while improving, remained inconsistent. Our observations showed that learning from training such as dementia care was not yet fully embedded into everyday practice.”

“Assessment and care planning processes also required further strengthening. Although the management team had reviewed assessments following the previous inspection, they were not always updated when people’s needs changed, limiting the service’s ability to identify deterioration and respond promptly. Risk management systems, including the use of Waterlow, MUST and NEWS tools, had begun to improve but were not yet embedded, with documentation not always reflecting current needs or the actions taken.”

“Environmental safety had improved, yet gaps remained, such as limited dementia‑friendly signage and issues with communal facilities, highlighting ongoing inconsistency in environmental oversight and quality assurance processes. Medicines processes had also improved but there remained shortfalls in the oversight of stock and quality assurance processes.”

“Governance and leadership arrangements were developing but not yet fully effective. While systems for monitoring incidents, reviewing documentation and analysing trends had been introduced, they were newly implemented and lacked evidence of sustained, consistent application.”

“Staff reported positive cultural changes under new management but noted that leadership visibility, accountability pathways and support were not yet fully established. Formal mechanisms for gathering feedback from people and relatives were limited, restricting opportunities for shared…”