CQC report explained · a residential care home
What the CQC found at Broadlands Park Residential 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
- Some risks were not assessed or managed, and care records contained contradictory information. There had also been occasions when staffing levels or deployment were not in line with assessed needs, although the provider had recently recruited more staff.
- Effective?
- Requires improvement
- Many staff did not have all the required up-to-date training. Mental capacity assessments and best-interest decisions were not always completed properly, and guidance for people with learning disabilities had not always been considered.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- The home's quality checks had not found several problems identified by inspectors, and some known concerns had not been dealt with promptly. The provider had an improvement plan and said it was addressing the issues.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found risks in care records, staff training, consent decisions and quality checks.
This was an unannounced focused inspection. Inspectors visited on 14 December 2022 and carried out further inspection work remotely until 2 February 2023. They spoke with people, relatives, staff and health professionals, observed care, and checked care, medicine and management records.
The home was not always safe or effective. Some risks were missing from care plans, and records contained conflicting information. Staff training was not up to date for many staff. Mental capacity assessments and best-interest decisions did not always follow the law. There had also been times when staffing levels and staff deployment were not enough.
There were also positive findings. Medicines were managed safely. People were treated kindly and offered choices. Staff worked well with health professionals, and food, drinks and the home environment were found to be suitable. However, the overall rating fell from Good at the last inspection in 2019 to Requires Improvement.
Safe medicines
Inspectors found that medicines were stored, administered and recorded safely. A medicine champion worked with the GP on medicine reviews.
“Staff managed medicines consistently and safely. Medicines were stored correctly and disposed of safely. Staff kept accurate medicine records.” from the report
Kind and respectful care
People and relatives said staff knew people well, offered choices and treated them with dignity. Staff spoke about taking time to make people happy.
“They take time and understand [them] better than me sometimes” from the report
Food and drink
People had enough food and drink, with support for their dietary needs. Inspectors saw a calm and unhurried lunchtime.
“The atmosphere was calm, relaxed and organised.” from the report
Clean environment and visiting
The home appeared clean, with cleaning schedules in place. Visiting was open and relatives said they could visit whenever they wanted.
“It's lovely now that we have open visiting. We don't have to plan and can pop in and see [person] when we want to.” from the report
Incomplete risk information
seriousSome risks were missing from care plans, including risks linked to movement, alcohol dependence and items that could be swallowed. Some records gave conflicting instructions about equipment and food presentation.
“This put people at risk of not receiving the care needed.” from the report
Staffing and deployment
needs fixingThere had been occasions when staffing numbers were below the home's assessed requirement. Inspectors also saw times when nobody was in a communal area while people needed supervision.
“On occasions we observed there were no staff in this area and witnessed a person exhibiting behaviour to show they were upset and people who were prone to falls trying to stand.” from the report
Training gaps
seriousThe provider could not show that all staff had current training. Training did not cover all the health and care needs of people living at the home.
“Overall, 44 staff had mandatory training expired or not completed.” from the report
Mental capacity decisions
seriousCapacity assessments were too broad and records did not show clearly how decisions had been made in people's best interests. An advance decision was not available in the person's records.
“The provider had failed to fully assess people's capacity and their records did not demonstrate decisions had been made in a person's best interests or appropriate people were involved in those decisions.” from the report
Weak quality checks
seriousThe home's checks did not identify all the problems inspectors found. Some concerns, including training issues, had not been addressed quickly enough.
“Quality assurance systems did not identify the areas of concerns identified at inspection.” from the report
Learning disability guidance
minorThe home had not fully used current guidance when planning care for people with learning disabilities. Inspectors recommended that the provider review its practice.
“We recommend the provider consider current guidance for people living at the service with a learning disability and take action to update their practice accordingly.” from the report
- 01What has been done to make sure every person's risks are recorded fully and that conflicting care instructions have been corrected?
- 02How many staff currently have up-to-date mandatory training, including training for diabetes, epilepsy, dementia, falls and learning disabilities?
- 03How are mental capacity assessments and best-interest decisions now checked, and are important documents such as advance decisions kept in people's records?
- 04How do you make sure there are enough staff in communal areas, particularly at night, later in the day and at weekends?
- 05What evidence can you show that your quality checks now identify and promptly address the problems found by CQC?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the previous ratings were carried forward. This explanation was written from the published report of 22 March 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, May 2019
Rated Good; inspectors found safe, kind and personalised care, with some care records needing clearer detail.
Inspectors visited without warning on 22 March 2019. They observed care, spoke with people, relatives, staff and healthcare professionals, and checked care records and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, clean premises, kind staff and care that was tailored to people's needs.
There were some gaps in records about people's mental capacity and best-interest decisions. The home was aware of this and had arranged further staff training. Audits had also found that some medicines records needed improvement, and procedures had been clarified.
Enough staff
Inspectors found enough staff to meet people's needs and spend time with them. Staffing was planned around people's needs.
“There were enough staff to meet people's needs and to spend time with them.” from the report
Kind and respectful care
Staff were described as kind, friendly and compassionate. Inspectors saw staff protecting people's dignity and giving support at the person's pace.
“We observed staff spending time with people. Interactions were positive and staff spoke with people in a respectful way.” from the report
Personalised support
Staff knew people's preferences, communication needs and interests. People could choose when to eat, follow hobbies and join trips.
“Care was personalised. Care plans recoded the way people preferred to receive care and support.” from the report
Good leadership
Staff understood their roles and felt supported. The home used audits, feedback and action plans to improve care.
“There was a quality assurance system in place to monitor all aspects of care and support provided” from the report
Some capacity records were unclear
needs fixingSome records did not clearly explain whether people could make particular decisions or what best-interest decision had been made. The home had arranged further training.
“Some records did not clearly document people's capacity to make decisions or the best interest decision made on their behalf.” from the report
Medicines recording needed improvement
needs fixingQuality checks found that some medicines records needed improvement. The home took action and made procedures clearer for staff.
“audits had identified that improvements were needed to some medicines recordings.” from the report
- 01What changes have you made to records about people's capacity and best-interest decisions?
- 02How do you check that medicines records are complete and accurate now?
- 03How quickly are call bells usually answered, and how do you monitor any delays?
- 04How will you involve our relative and family in recording care preferences and end-of-life wishes?
- 05Which activities, trips and communication support would be available for our relative?
This was a planned inspection covering all five CQC questions, including the care provided and the premises. This explanation was written from the published report of 10 May 2019 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 Broadlands Park Residential Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Broadlands Park Residential Care Home →
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
Read what inspectors found at Broadlands Park Residential Care Home →
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015
Registered with the Care Quality Commission on 1 January 2015.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.