We carried out a review of the data available to us about Broadleigh Nursing Home 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 Broadleigh Nursing Home, you can give feedback on this service.
Broadleigh Nursing Home is a nursing and residential care home providing personal and nursing care for up to 37 older people, some whom may be living with dementia. At the time of the inspection there were 34 people living at the service.
The provider is also registered for the regulated activity of Diagnostic & Screening although this was not being provided at the time of this inspection.
People’s experience of using this service and what we found
Quality assurance systems were in place to monitor how well the service was running and identify any improvements that were required. For example, relating to people’s skin integrity.
The provider engaged people, their relatives and staff in giving their views about how the service could improve.
Relatives all told us their family members felt safe and well supported. Risks were identified, assessed and regularly reviewed.
We found that there was enough staff available to meet people’s needs. Staff felt well supported and received training appropriate for their roles. People were given their medicines safely and staff followed infection prevention and control procedures with the exception that not all staff were wearing their mask appropriately.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
We have made a recommendation to undertake further fire safety drills to ensure that their protocols work in the event of an emergency.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was good (published 13 August 2022)
Why we inspected
We received concerns in relation to staffing levels, records and safety. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Broadleigh Nursing Home is a nursing and residential care home providing personal and nursing care to 30 people aged 65 and over at the time of the inspection. The service can support up to 37 people.
The provider is also registered for the regulated activity of Diagnostic & Screening although this was not being provided at the time of this inspection.
People’s experience of using this service and what we found
There was no registered manager in post, but the service was well managed by the current manager. Improvements had been made to people’s care records and risk assessments.
The provider and the quality manager had introduced new system policies and procedures to help improve and guide staff with what action to take especially around incidents of safeguarding. We now need to see these embedded into practice. Staff demonstrated a good understanding of how to keep people safe from harm or abuse. They also confirmed that they would report any concerns they may have to senior staff.
Staff knew the people they supported well. There were enough suitably trained and knowledgeable staff to help support people’s care and support requirements in a timely manner. People felt safe and told us the staff looked after them well. People were encouraged to eat and drink healthily to help promote their wellbeing.
Governance systems were used in the service. There were action plans in place to drive improvements throughout service. There was an overview of accidents and events and these were reviewed to help ensure there was not a reoccurrence. Medicines were managed safely.
The manager and staff promoted satisfactory infection control and cross contamination processes.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 25 November 2019). There were multiple breaches. The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was carried out to follow up on the action we told the provider to take at the last inspection.
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 COVID-19 and other infection outbreaks effectively.
The overall rating for this service has changed from requires improvement to good. This is based on the findings at this inspection.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People’s experience of using this service and what we found
People were placed at risk of harm because safeguarding procedures had not always been followed. Risk assessments and care plans did not always provide staff with all the information they required to keep people safe. Staff did not always treat people with respect and kindness and people’s dignity was not always upheld.
Although accidents and incidents had been analysed the information was not always shared with staff so that lessons could be learnt, and preventative action taken.
Since the registered manager had left the home there was a lack of managerial oversight. This meant that the service was not well led. Where issues had been identified actions had not been taken to ensure improvements were made in a timely manner.
Staff received the support and training they required to carry out their roles. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People's care plans did not always contain sufficient or accurate information for staff to be able to support them. Complaints had not always been recorded, investigated or the appropriate action taken to prevent a reoccurrence.
Thorough recruitment procedures had been followed to ensure staff were suitable to work with vulnerable people. People had sufficient food and drinks throughout the day. A variety of activities were offered for people to take part in. People were supported to access health professionals and to attend appointments.
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 (report published 13 May 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified breaches in relation to keeping people safe from harm, risk assessments, identifying areas for improvement and notifying the commission of changes.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will meet with the provider to discuss how they will make the changes to ensure they improve their rating to at least good. We will also request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
This comprehensive inspection took place on 4 April 2017 and was unannounced.
At the last inspection on 5 April 2016 a breach of legal requirements was found and the service was rated as Requires Improvement. After the comprehensive inspection the provider wrote to us to say what they would do to meet the legal requirement in relation to improvements to the variety of food that was available to meet people’s needs. The provider sent us an action plan telling us how they would make the required improvements.
During this inspection we found that the provider had made the necessary improvements and the legal requirement was now being met. This means that the service is now rated as Good.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.
At the last inspection, undertaken on 5 April 2016, we found there was a breach of one legal requirement because people were not offered an appropriate variety of food that was available to meet their needs. We saw that there had been improvements made to meet the relevant requirement.
The risk of harm for people was reduced because staff knew how to recognise and report any incidents of harm. There was a sufficient number of staff to meet the care and support needs of people living in the home. Satisfactory pre-employment checks were completed before staff worked in the home.
The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS), which apply to care services. People’s capacity to make decisions for themselves had been assessed. Staff were trained in the principles of the MCA and DoLS and could describe how people were supported to make decisions. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People were able to make choices about their food and drink throughout the day. Staff checked that people had sufficient amounts to eat and drink. Staff treated people with care and respect and made sure people’s privacy and dignity was respected.
People and staff were able to provide feedback and information so that the management could monitor and improve the quality of the service. The management team had an open door policy which meant anyone could make a complaint and make comments or improvements about the care and support provided.
This unannounced inspection took place on 5 April 2016.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 scheme is run.
People had their needs assessed and reviewed so that staff knew how to meet their care needs. Information in people’s care plans had not always been updated where there had been changes in a person’s needs.
The risk of harm for people was reduced because staff knew how to recognise and report abuse. There was a sufficient number of staff to meet the care needs of people living in the home. Satisfactory pre-employment checks were completed before staff were employed to care for people in the home.
Risks to people had not always been kept up to date. This meant that staff did not always have the information they needed to reduce risks.
The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Staff were trained in the principles of the MCA and DoLS and could describe how people were supported to make best interest decisions. The registered manager had made applications so that people were only deprived of their liberty in a lawful way.
People were supported to take their medicines as prescribed and medicines were safely managed.
An effective induction process was in place to support new staff and further training was provided to ensure all staff had the necessary expertise to meet people’s needs.
People did not always have sufficient food and drink of their choice throughout the day. Although staff knew people’s likes and dislikes they were not always taken into account. People were supported by kind, caring and happy staff. People’s privacy and dignity was respected by staff.
A range of audit and quality assurance procedures were in place. These were used as a means of identifying areas for improvement and also where good practice had been established. However, these had not always been effective in identifying the omissions we found. Information to assess the quality of the service was gained through telephone surveys, quality questionnaires and staff meetings.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
As part of this inspection we spoke with six people who used the service and one visitor. We also spoke with the manager, a Director who represented the provider, and three members of staff. We also reviewed records relating to the management of the service which included four care plans, daily records, staff records and quality assurance monitoring records.
Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.
If you want to see the evidence that supports our summary please read the full report.
This is a summary of what we found:
Is the service safe?
Risk assessments for care needs were completed and provided appropriate guidance for the identified risk to be reduced. One person said that they were not involved in reviewing their care plan, although their relative had been, and they were supported to make decisions regarding their immediate care needs and wishes.
People received the care and support they required to improve their health and well-being. Care records were written in enough detail to provide clear guidance to staff members. Reviews of care plans were completed so that staff had guidance about how to support each person safely.
Applications had been appropriately made in regard to Deprivation of Liberty Safeguards for people whose liberty was restricted. Staff members and the manager showed they had appropriate knowledge regarding recent guidance.
Medicines were stored appropriately and records were maintained to show all storage areas were kept at the correct temperature. Administration records were kept and people received their medicines in a safe way.
Is the service effective?
People told us that staff members helped them with everything they needed assistance with. They told us that they were satisfied with the care they received. Care records provided clear and detailed information about people's care needs and preferences.
They told us and we observed that staff members told people what they were going to do before carrying out any tasks and gave people the opportunity to decline if they wished. However, one person said sometimes they were helped to bed before they wanted to go.
Assessments of people’s mental capacity were completed and information was available to staff members if people did not have the capacity to make certain decisions.
Health needs were responded to and people had access to health care professionals if they needed this. Information and guidance given by health care professionals was included in people’s care records so that staff members knew how to promote their health.
People told us they liked the meals that were provided. We found that a choice was not offered, but that people could request an alternative if the menu meal was not to their liking. We saw that staff appropriately supported people to eat and drink when they needed help with this.
Staff members received supervision and training from the provider or from external sources to ensure they had the skills and support to properly carry out their roles and care for people.
Is the service caring?
People said that staff members were polite and kind; they respected people's privacy and dignity, and involved them in their care. Staff members knew people's care needs and their personal preferences when we spoke with them.
We observed interactions between people and staff members and we found that the members of staff were patient and understanding of people's individual needs.
Is the service responsive?
We saw that people's individual physical and mental support, care and treatment needs were assessed and planned for. Their individual choices and preferences regarding their support and care were also respected.
Is the service well led?
There had been twice yearly surveys issued to gather the views of people who used the service last year and further information was gathered using telephone questionnaires. Responses from the last survey were positive. There were other systems in place to monitor and assess the quality of the service provided; the service had analysed this information for any trends or themes resulting from complaints, accidents or incidents.
We undertook a follow-up inspection on 20 August 2013 and found that adequate staff supervisions, appraisals and training systems were now in place to ensure that people who used the service received safe and appropriate care from suitable staff.
We did not speak to any staff members during our inspection on 20 August 2013. However, during our last inspection on 14 May 2013 we spoke with three members of staff and they told us that they felt supported by the provider as they resolved any concerns they may have about people using the service.
Staff had access to detailed care records to ensure that they provided people with safe, appropriate, individual support and care. A person who used the service who we spoke with told us that, "Help and support (given) is to a good standard." Another person we spoke with went on to tell us that the standard of care delivered was, "(Of) a high standard. They (staff) treat you as an individual and speak to you respectfully."
People were protected from the risk of infection spreading as there were effective systems in place to reduce the risk.
On examination of the provider's training records we saw that some staff had not undertaken training updates. These updates would ensure that staff had the most up to date knowledge to deliver safe care and support to people who used the service.
We saw that an effective quality assurance system was in place as the provider used the results from surveys and audits to monitor, maintain and where appropriate improve the quality of the service delivered.
People were also supported to access health care services and a professional whom we spoke with told us that they felt people were. ‘Well cared for and looked after" and that communication with the provider was." Good".
Effective staff recruitment was in place to make sure that people who used the service received support and care from suitable, skilled, and knowledgeable staff.
Also, an effective complaints procedure was in place and that meant that people's comments and complaints were listened to and acted upon in a timely manner.