CQC report explained · a residential care home
What the CQC found at Broadland View Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found weaknesses in safeguarding, risk management, staff checks and learning from incidents. Medicines and infection control were generally managed well, but some safety risks were not dealt with promptly.
- Effective?
- Good
- This question was not inspected during this focused visit, so its previous rating was carried forward for the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit, so its previous rating was carried forward for the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit, so its previous rating was carried forward for the overall rating.
- Well-led?
- Requires improvement
- Leadership and provider oversight did not consistently identify or control risks. Audits had not found the concerns inspectors identified, and records did not always clearly show people's health and welfare.
What inspectors found, April 2023
Broadland View Care Home was rated Requires Improvement; inspectors found kind care but serious weaknesses in safeguarding, risk management and leadership.
This was an unannounced focused inspection on 20 February, 22 February and 1 March 2023. The inspection looked at Safe and Well-led. Inspectors spoke with people, relatives, staff and healthcare professionals, and reviewed care plans, medicines records and other safety records.
People and relatives were mostly positive about the care. Staff were described as kind, there were enough staff, medicines were generally managed well, and the home was clean. However, safeguarding concerns had not always been reported, action to protect people was not always prompt, and some staff checks were incomplete.
Inspectors found risks linked to choking, falls, blood-thinning medicines and the environment were not always properly managed. A faulty sensor mat remained in use and a hot tap had not been repaired. Records did not always give a clear picture of people's health and welfare.
The overall rating changed from Good at the previous inspection to Requires Improvement. The provider had started new checks, a care plan review and staff reminders, but CQC issued a warning notice and will monitor an action plan.
Kind staff and positive relationships
People and relatives gave positive feedback. Inspectors found staff were kind and knew people's preferences well.
“There were enough staff and staff knew people's preferences well. They were very kind and relationships were good.” from the report
Medicines generally managed well
People received their medicines as prescribed and most medicines records were accurate. The medicines room was organised and storage checks were in place.
“Medicines were well managed and accurate records were maintained. The member of staff administering medicines on the day of our inspection demonstrated a good knowledge and understanding of medicines.” from the report
Enough staff
Inspectors found enough staff to meet people's needs and a visible staff presence in communal areas. Rotas showed staffing was stable.
“There were enough staff to meet people's needs and there was always a visible staff presence in all the communal areas of the service.” from the report
Clean home and infection control
The home was clean and odour free. Staff used protective equipment appropriately and infection control procedures were in place.
“The service was clean and odour free. Effective cleaning procedures were in place. Staff wore personal protective equipment (PPE) appropriately” from the report
Safeguarding was not handled reliably
seriousSafeguarding concerns were not always referred to the local authority or reported to CQC. The provider did not always act promptly to protect people from continuing risk.
“Safeguarding concerns had not always been appropriately identified and referred to the local authority or reported to CQC.” from the report
Important risks were not controlled
seriousRisk information about choking and falls was incomplete or not understood by all staff. A faulty sensor mat remained in place, and a hot tap that could scald had not been repaired.
“We established this mat was still in place at the time of our inspection and was faulty.” from the report
Leadership checks missed problems
needs fixingAudits had not identified the concerns found by inspectors. Some records were kept in different places and did not give a reliable picture of one person's health.
“Recent audits had not identified the concerns we found.” from the report
Some staff oversight was incomplete
needs fixingSome staff did not have safeguarding training recorded, and staff promoted to senior roles did not always receive enough supervision. Previous care employment checks were not always robust.
“Staff were recruited to senior roles without having had leadership experience. They were not always given sufficient supervision and monitoring to ensure their continued safe practice.” from the report
Medicine errors were not fully investigated
needs fixingRecent medicine administration errors had not always been fully investigated when they happened. One competency check was missing and another had not initially been recorded.
“Some recent medicines administration errors had not been fully investigated at the time they occurred.” from the report
- 01What has been done to make sure every safeguarding concern is reported to the local authority and CQC when required?
- 02Have the faulty sensor mat and the over-hot tap been repaired or replaced, and how are environmental risks now checked?
- 03How are choking risks and falls risks for people taking blood-thinning medicines recorded and explained to every member of staff?
- 04What new audits are now in place, and how will you show that they identify problems promptly?
- 05How are medicine errors investigated and staff competency checks recorded?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection in 2017. This explanation was written from the published report of 28 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2017
Rated Good; inspectors found safe, kind and responsive care, with improvements needed after earlier concerns.
This was an unannounced comprehensive inspection on 24 and 25 October 2017. One inspector and an expert by experience observed daily care, meals, medicines and activities. They spoke with people, relatives, staff and a visiting district nurse, and reviewed care, medicine, staffing and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable care plans, good support with food and drink, kind staff and meaningful activities. People were involved in decisions and health concerns were referred on promptly.
The inspection followed earlier breaches about person-centred care, consent, nutrition and governance. Inspectors said the home had made sufficient improvements and was no longer breaching those requirements. They did note gaps in some medicine records and an occasion when people needed more help during a meal, but action was taken during the inspection.
Kind and respectful staff
Inspectors saw staff treating people with warmth, patience and respect. They supported privacy and dignity and knew people's individual needs and preferences.
“Staff working in the home were caring and compassionate.” from the report
Improved care planning
Care plans included people's histories, preferences, risks and required support. They were reviewed and updated when people's needs changed.
“Care plans and assessments were comprehensive and showed how people's needs were to be met and how staff should support people.” from the report
Food and drink support
People were offered choices and had access to drinks throughout the day. Dietary needs, preferences and risks of poor nutrition were recorded and monitored.
“People were supported to have sufficient to eat and drink and to maintain a balanced diet.” from the report
Activities and social contact
The home offered group and individual activities, including activities for people who preferred to stay in their rooms. Inspectors found this helped reduce the risk of isolation.
“People were offered a wide range of both group and individual activities that were meaningful to them and which had a positive impact on their lives.” from the report
Open management
Staff said management was approachable and listened to concerns. The provider visited weekly and quality checks were used to monitor care.
“There were effective quality assurance systems in place to make sure areas for improvement were identified and addressed in a timely way.” from the report
Gaps in medicine records
needs fixingInspectors found gaps in some medicine administration records. The home suspended the staff involved from giving medicines until retraining and competency checks were completed.
“However, we found in some records that there were gaps in these records.” from the report
Support at one mealtime
needs fixingOn the first day, three people who needed encouragement or help with their meals were left unsupported. Food became difficult to eat or went cold, although the manager acted immediately and inspectors saw improvement the next day.
“On the first day we observed three people on the same table, left unsupported who were struggling with their meals.” from the report
- 01How do you check that medicine administration records are complete every day?
- 02What staffing arrangements are in place at mealtimes for people who need encouragement, help cutting food or special equipment?
- 03How will you make sure the improvements found at this inspection continue over time?
- 04How are my relative's choices, communication needs and consent recorded and reviewed?
- 05How will you support my relative with activities if they prefer to spend time in their room?
This was a comprehensive inspection covering all five CQC questions and checking whether improvements after earlier inspections had been made and sustained. This explanation was written from the published report of 2 December 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Broadland View Care Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2017Requires improvementstayed Requires improvementWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- August 2013
Registered with the Care Quality Commission on 8 August 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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