21 March 2023
During an inspection looking at part of the service
Broughton Lodge is a residential service providing personal care for up to 18 older people some of whom are living with dementia. The service consists of an adapted building, which includes individual bedrooms, communal spaces and an accessible outdoor space. At the time of our inspection there were 16 people using the service.
People’s experience of using this service and what we found
People told us they felt safe with the care and support they received. However, despite mostly positive feedback, we found shortfalls with the management of people’s risks and quality assurance systems which placed people at increased risk of harm.
Systems in place to monitor the quality and safety of the service did not identify and address the shortfalls we found during the inspection.
Not all risks to people had been sufficiently assessed. People received their medicines safely and as prescribed, however we found some minor issues with the management of medicines.
Staff had received safeguarding training and understood their responsibility to report any concerns. Appropriate staff recruitment procedures were in place; however, recruitment records were not always well documented. There were enough staff to keep people safe and meet their needs. Staff followed safe infection prevention and control measures.
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.
Staff told us they felt supported and morale within the staff team was good. People and their relatives spoke positively of staff and told us they were satisfied with the service.
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 February 2019). There have been two targeted inspections since this inspection, published July 2020 and February 2022. These did not change the rating.
At our inspection published July 2020 we recommended that the provider review the published guidance on developing care plans for people with specific behavioural support needs. At this inspection we found sufficient action had not been taken in response to this recommendation.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
Enforcement
We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will 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 continue to monitor information we receive about the service, which will help inform when we next inspect.