Brendoncare Mary Rose Mews was rated overall Good at its May 2016 inspection, with Safe rated Requires Improvement due to a regulatory breach (Regulation 19) for incomplete staff recruitment records and absence of post-training medicines competency assessments. All other key questions were rated Good, reflecting strong person-centred care, effective staff support, and robust governance processes.
Concerns (3)
critical
Record keeping
: “Two of the staff employment records reviewed did not contain photographic evidence of their identity or a full employment history.”
criticalGovernance: “The provider had failed to ensure that all of the required information was available in relation to each staff member employed. This was a breach of Regulation 19 (3).”
moderateStaff competency: “The domiciliary care supervisor told us they did not assess staff competency to administer medicines following completion of their training.”
Strengths
· People consistently reported feeling safe and receiving care from familiar, consistent staff who arrived on time and stayed for the agreed duration.
· Staff demonstrated warm, caring relationships with people, respecting privacy, dignity, and individual preferences in care delivery.
· Robust safeguarding processes including training, supervision discussions, and body maps were in place to protect people from abuse.
· People were supported to maintain independence, make decisions, and avoid social isolation through personalised, person-centred care.
· Effective governance processes including monthly audits, incident reviews, staff training monitoring, and regular quality questionnaires.
Quality-Statement breakdown (19)
safe: Staffing levels and consistencyGood
safe: Recruitment practicesRequires improvement
safe: SafeguardingGood
safe: Risk managementGood
safe: Medicines managementRequires improvement
effective: Staff training and inductionGood
effective: Supervision and supportGood
effective: Consent and Mental Capacity ActGood
effective: Nutrition and hydrationGood
effective: Healthcare accessGood
caring: Caring relationships and staff attitudeGood
caring: Involvement in decisionsGood
caring: Privacy and dignityGood
responsive: Person-centred care planningGood
responsive: Support for independence and social inclusionGood
responsive: Complaints handlingGood
well-led: Leadership and management arrangementsGood
Brendoncare Mary Rose Mews, an extra care housing service in Alton serving 15 people, maintained an overall Good rating at its August 2018 inspection, having remediated its sole previous breach around recruitment processes. All five key questions were rated Good, with no current regulatory concerns identified.
Strengths
· Previous breach of Regulation 19 (recruitment) resolved; robust recruitment processes now in place including full employment history, DBS checks, and right-to-work verification.
· People consistently reported feeling safe, treated with kindness and dignity, and not feeling rushed during care.
· Medicines management was thorough: trained staff, annual competency assessments, pictorial guidance for topical creams, and monthly MAR audits.
· Person-centred care approach with 'This is me' profiles, flexible visit scheduling, and involvement of people in care planning and risk assessments.
· Strong governance: weekly reports to general manager, monthly medicine audits, monthly incident trend analysis, staff supervision and appraisal monitoring.
Quality-Statement breakdown (22)
safe: Safeguarding people from abuseGood
safe: Risk assessment and managementGood
safe: Staffing and recruitmentGood
safe: Medicines managementGood
safe: Infection controlGood
safe: Incident learning and reviewGood
effective: Assessment of care needsGood
effective: Staff skills, knowledge and trainingGood
effective: Nutrition and hydration support
Good
effective: Multi-agency and cross-organisational workingGood