CQC report explained · a nursing home
What the CQC found at Broadleigh Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some safety records and guidance were not reliable enough. Staff did not always wear masks correctly, and the home was asked to carry out further fire drills, including when staffing was lowest at night.
- Effective?
- Good
- This area was not assessed during the focused inspection, so no new rating was given.
- Caring?
- Good
- This area was not assessed during the focused inspection, so no new rating was given.
- Responsive?
- Good
- This area was not assessed during the focused inspection, so no new rating was given.
- Well-led?
- Good
- The home had quality monitoring, gathered feedback and responded to concerns. However, management checks had not ensured that staff wore PPE correctly.
What inspectors found, February 2023
Rated Good overall, but inspectors found safety needed improvement because care records, fire drills and mask-wearing were not always adequate.
This was an unannounced focused inspection on 9 December 2022. It was carried out after concerns about staffing, records and safety. The inspector reviewed care and medicine records, recruitment files and management documents, and spoke with people, relatives and staff.
The home had enough staff, medicines were managed safely and people and relatives said they felt safe and supported. Risks were identified and reviewed, but care plans did not always give enough detail about reducing risks. Repositioning records for people at risk of pressure sores were not consistently completed.
The home was rated Good overall. Safe was rated Requires Improvement, down from Good at the previous inspection, while Well-led remained Good. The other three areas were not assessed during this focused inspection.
Staffing
Inspectors found enough staff to meet people's care and support needs. Recruitment was continuing, with rota gaps covered by overtime.
“There were enough staff to meet peoples care and support needs.” from the report
Medicines
Medicines were given safely. Administration and returns records were well kept, and staff had training and competency checks.
“The records were well kept for both administration and the return of medicines.” from the report
Safeguarding and choice
Staff understood how to report abuse and concerns. People were asked for permission before personal care, and mental capacity processes were in place.
“People told us staff sought their permission before providing personal care.” from the report
Positive leadership
Relatives spoke positively about the home's culture and communication. Managers responded immediately to the inspectors' feedback and created action plans.
“Family members spoke positively about the culture within the home.” from the report
Listening to feedback
People, relatives and staff had opportunities to suggest improvements. The home had acted on suggestions about activities and the menu.
“People had regular opportunities to feedback their experience of the service and suggest improvements.” from the report
Care risk records
needs fixingCare plans did not always explain clearly how risks should be reduced. Repositioning records for people at risk of pressure sores were not consistently completed.
“Although staff we spoke with knew people well, information in care plans did not provide detailed guidance on how the risks could be minimised.” from the report
Mask wearing
needs fixingInspectors saw staff wearing masks under their noses or with masks slipping down. Management oversight had not made sure PPE was used correctly.
“However, we saw instances where staff's masks were under their nose or slipping down.” from the report
Night-time fire drills
minorFire drills had not been carried out when staffing was at a minimum, especially at night. Inspectors recommended a drill to test whether the home's emergency arrangements worked in those circumstances.
“We have recommended that as part of fire safety a drill is undertaken to ensure that it is effective as detailed in their risk assessment especially if an incident occurred during the night.” from the report
- 01What changes have you made to care plans so staff have clear guidance about reducing each person's risks?
- 02How do you now check that repositioning records for people at risk of pressure sores are completed consistently?
- 03Have you completed fire drills with minimum staffing, including at night, and what did you learn from them?
- 04How do managers check that staff wear masks correctly throughout each shift?
- 05What improvements have been made since the Safe rating changed from Good to Requires Improvement?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not assessed in this inspection. This explanation was written from the published report of 16 February 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, August 2021
Broadleigh Nursing Home was rated Good; inspectors found safe, kind care and improvements since the previous inspection, but communication and leadership arrangements still need attention.
This was an unannounced follow-up inspection on 12 and 26 July 2021. Inspectors spoke with six people, seven staff members and five relatives. They reviewed care records, medicine records, staff recruitment files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines management, improved care plans and risk assessments, kind care, and support that reflected people's choices.
The previous rating was Requires Improvement, with several breaches. Inspectors found enough improvement had been made and the home was no longer in breach of regulations. There was no registered manager, and the home still needed to improve how it tracked actions and communicated with relatives.
Safe staffing
Inspectors found enough suitably trained staff to meet people's needs in a timely way. Recruitment checks were also completed.
“There were enough staff to support people's care needs in a timely manner.” from the report
Safe medicines
Medicines records were accurate, storage was appropriate, and staff had training and regular competency checks.
“Medicines continued to be managed safely so that people received their medicines as the prescriber intended.” from the report
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors observed staff giving people time and treating them with dignity.
“There was a warm, friendly atmosphere throughout the service and staff were kind, caring and respectful.” from the report
Personalised support
Care plans reflected people's preferences and staff used their knowledge of people's lives and interests to engage with them.
“Person-centred care plans had been developed and further information was being included to enable staff to support people in a personalised way.” from the report
No registered manager
needs fixingThere was no registered manager when inspectors visited. The current manager said they planned to apply for registration.
“There was no registered manager in post. The current manager has told us they will be applying to register.” from the report
Action plans were difficult to track
needs fixingThe home had several action plans from audits, but these were not combined, making it difficult to see what was complete or still outstanding.
“This made it difficult to see the overall picture of actions required and track whether actions had been complete or were still outstanding.” from the report
Communication with relatives
needs fixingRelatives gave mixed feedback. Some were unsure who to contact and said responses were not always consistent. The provider accepted that communication needed further improvement.
“The communication isn't always very good and the responses are often inconsistent.” from the report
- 01Has the manager applied to register with the CQC, and what is the expected timescale?
- 02How are you combining the separate action plans, and how can families see which actions are complete?
- 03Who should relatives contact with concerns or complaints, and how will responses be kept consistent?
- 04How will you keep relatives informed about changes in management?
- 05How are staffing levels reviewed as people's care needs change?
This was an unannounced follow-up inspection of all five quality areas, including infection prevention and control, after the previous Requires Improvement rating and breaches. This explanation was written from the published report of 13 August 2021 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 Broadleigh Nursing Home
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
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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