Background to this inspection
Updated
22 March 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was carried out by 2 inspectors and 2 Expert by Experiences, one attended the inspection and the other spoke with relatives by telephone afterwards. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Broadlands Park is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Broadlands Park is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced. Inspection activity started on 14 December 2022 and ended on 2 February 2023 when final feedback was given, with some aspects of the inspection being carried out remotely. We visited the location’s service on 14 December 2022.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.
During the inspection
We spoke with 14 relatives, 4 people who used the service, 16 staff including activities lead, care workers, care facilitators, deputy manager, managers including the provider and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We received feedback from 3 health care professionals. We observed people’s care and support. We reviewed a range of records. This included 10 people’s care records and multiple medication records. We looked at 3 staff files in relation to recruitment and a variety of records relating to the management of the service, including audits, policies and procedures were reviewed.
Updated
22 March 2023
About the service
Broadlands Park is a residential care home providing personal care to up to 34 older people some of whom were living with dementia. At the time of our inspection there were 33 people using the service.
People’s experience of using this service and what we found
The provider’s quality assurance system had not been effective at identifying concerns which were found during inspection. Not all risks had been identified and assessed to mitigate any harm they posed to people living in the service. The auditing processes had not identified contradictory information held within care records. This put people at risk of not receiving the care needed.
Staff had not received all the training required to meet their roles and needs of people who lived in the service. Although we had concerns regarding the deployment and numbers of staff, the situation had improved recently with increased recruitment including sponsorship of new staff.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, mental capacity assessments and best interest decision did not follow Mental Capacity Act guidance.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic and have made a recommendation the service reviews this to ensure it is meeting the requirements.
Medicines were managed consistently and safely. There was a medicine champion who oversaw the administration and worked closely with the GP to review the use of medicines.
People were given choices to ensure their needs were meet. A relative said, “[Person] has no problem with male or female staff. The service definitely meets [their] needs. [They] were wasting away in [their] bedroom at home and in here [they’re] looked after and has got company. [They] are happy. I’m happy. I’ve had a review of what they’re providing.”
Staff spoken to all said they enjoyed their job and how much they cared. One said, “Seeing [people] smile and you know you have done your job.” Another said, “doing little bits for individual people can make their day, just once a day, a little glint in their eye, a smile or remembering something. Anything. It is good to make people happy.”
The service had developed good relationship with health care professionals including the local GP. They had staff who were champions in such things as falls, continence and wound care, who ensured referrals were made in a timely way and these were chased so there was limited delay in people receiving the treatment they needed. Regular visits took place by GP and other Health care professionals who spoke very highly of the staff’s knowledge and experience. During these visits people with complex needs were discussed to ensure all available support was being provided.
The provider responded promptly to areas of concern raised with them and review systems and put appropriate measures in place to address shortfalls.
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 10 May 2019).
Why we inspected
We received concerns in relation to management of people’s falls. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement and Recommendations
We have identified breaches in relation to risk management, adherence to the Mental Capacity Act 2005 (MCA), staff training and governance at this inspection. We have also made a recommendation the provider considers current guidance for people living at the service with a learning disability to ensure they are meeting the requirements.
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 following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.