Brockenhurst

The following is CQC's published account of its assessment, published 21 April 2026. References to “we” mean CQC. It describes findings at that time.

Date of Assessment: 3 February to 27 February 2026.

Brockenhurst is a residential care service providing support to up to 38 older people living with dementia. At the time of the inspection, there were 25 people using the service.

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 learning and service development.

Despite these areas of concern, Brockenhurst demonstrated several positive developments. The culture of the service was improving, with staff describing leadership as more open, supportive and modern. External healthcare professionals reported that leaders were responsive, valued professional input and acted on recommendations, contributing to better clinical oversight and more consistent escalation processes.

Safeguarding knowledge and reporting had strengthened, and people and relatives generally felt safe and were confident that staff would respond appropriately to concerns. The environment had undergone improvements to enhance safety, such as adjustments to stairway access and strengthened maintenance checks, and prompt action was taken when infection prevention issues were identified.

People and relatives frequently spoke positively about staff, describing them as kind, compassionate and welcoming. Staff were observed offering reassurance and emotional support, and many were knowledgeable about people’s preferences and personal histories. The management team had taken steps to review and improve care plans, strengthen collaboration with external professionals, and develop clearer processes for monitoring risk, recognising deterioration and improving outcomes. Leaders remained committed to developing the service, embedding new systems and supporting staff through ongoing change.