CQC report explained · a residential care home
What the CQC found at Broadoaks
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2021
Broadoaks rated Requires Improvement; inspectors found risks linked to staffing, records and management checks.
This was an unannounced inspection on 25 August 2021. Inspectors spoke with people and staff, observed care, and checked care, medicine, staffing and management records.
The home was not always able to show that enough staff were deployed. People were sometimes left waiting or in areas without staff. Care records and risk information were not always up to date, and some falls and safeguarding concerns were not reported or reviewed properly.
There were also positive findings. People received their medicines as prescribed. Staff had training, used protective equipment appropriately and worked with health professionals. However, the overall rating fell from Good in 2018 to Requires Improvement because inspectors found breaches in staffing and good governance.
Medicines
People received their medicines as prescribed. Staff knew how people preferred to take them and completed medicine records accurately.
“People received their medicines as prescribed and staff had clear information about how people liked to be supported with their medicines.” from the report
Infection control
Inspectors were assured that staff used protective equipment safely and that the home had measures to prevent and manage infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff training
Staff were safely recruited and their training was up to date at the time of inspection.
“Staff were safely recruited to the service, and were provided with relevant training for the roles they undertook.” from the report
Working with professionals
The home sought advice from district nurses, occupational therapists and physiotherapists, and included this information in care plans.
“The provider worked well with external professionals, and sought guidance and advice on how to provide care to the people living in the service.” from the report
Staffing and waiting
seriousStaffing was not based on a tool that matched staff numbers to people's needs. People did not always receive help promptly, and some areas were left without staff.
“We found people did not receive timely support from staff and at times people were left waiting.” from the report
Risk and falls records
seriousRisk assessments and care plans did not always explain how people should be supported safely. Investigations into falls did not consistently identify actions to reduce future risks.
“We could not be assured that lessons were learned or shared with staff following incidents, as there was no details of changes or reviews following incidents.” from the report
Safeguarding reporting
seriousSome safeguarding concerns and unwitnessed falls causing injuries were not reported correctly. Some notifications to CQC were made retrospectively after the inspection.
“Two service users had unwitnessed falls, resulting in injuries, that had not been reported correctly.” from the report
Management checks
seriousThe home's quality checks had not found the problems identified by inspectors in staffing, safeguarding, falls and care documentation.
“The providers governance and overview processes were not robust.” from the report
Consent and capacity
needs fixingRecords did not always show that people had consented to their care, or that decisions for people lacking capacity followed the required process.
“We could not be assured that decisions made by the provider were in the persons best interest, and the least restrictive.” from the report
- 01How many staff are now deployed on each floor at different times of day and night?
- 02How do you match staffing levels to each person's changing needs?
- 03What has changed in care plans and risk assessments after falls or distress-related incidents?
- 04How do your management checks now identify missed records, safeguarding concerns and staffing problems?
- 05How do you record consent and make best-interest decisions for people who may lack capacity?
This was a focused inspection prompted by concerns about staffing and risks; only Safe and Well-led were inspected, while the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 7 October 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.
What inspectors found, December 2018
Rated Good; inspectors found safe, kind care, but care plans did not always fully record people's needs.
Inspectors visited without notice on 3 and 5 October 2018. They spoke with people living in the home, relatives and staff. They reviewed care files, staff records, medicines records, staffing information, complaints and quality checks.
The home was rated Good overall. Safe, Effective, Caring and Well-led were rated Good. Responsive was rated Requires Improvement because some care plans did not fully or accurately record people's needs and risks.
Inspectors found enough staff, safe medicines arrangements, suitable training and kind care. People's food, drink and healthcare needs were met. People were involved in decisions, could join activities and knew how to raise concerns.
The previous inspection had found problems with staff training and management systems. The report says these improvements had been made. The home was given one recommendation to strengthen care planning.
People felt safe
People said they felt safe and staff understood safeguarding procedures and people's individual risks. Inspectors found suitable staffing and recruitment arrangements.
“People told us the service was a safe place to live and there were sufficient staff available to meet their care and support needs.” from the report
Kind and respectful care
Staff were described as friendly and caring. Inspectors saw staff respecting privacy, dignity and independence.
“Staff were friendly, kind and caring towards the people they supported and the care provided met people's needs.” from the report
Training had improved
The report says earlier problems with staff training and induction had been addressed. Staff received training linked to people's specific needs.
“At this inspection, we found that the required improvements as detailed above had now been made and 'Effective' was now judged as 'Good'.” from the report
Food and healthcare
People's nutrition and hydration were monitored, and healthcare professionals were involved when needed. People spoke positively about meals and healthcare support.
“People had their nutrition and hydration needs met and the dining experience was positive.” from the report
Care plans did not always show current risks
needs fixingSome risks had not been recorded fully, with suitable control measures. Inspectors did not find an impact on people's care during the visit, but said records needed improvement.
“Not all risks had been identified and suitable control measures put in place to mitigate the risk or potential risk of harm for people using the service.” from the report
Some care plans were incomplete
needs fixingTwo newer residents did not yet have complete care plans covering all their care needs and the support staff should provide. The service was asked to review best practice in care planning.
“Two people who were admitted to the service in June and September 2018, did not have a complete care plan in place detailing all their specific care needs and the delivery of care to be provided by staff.” from the report
Minor medicines records gaps
minorRecords did not always show that topical creams had been applied each day. One person who gave themselves eye drops had not been formally assessed for safety.
“Minor improvements were required to evidence where topical creams were required to be applied to people's skin each day.” from the report
- 01How will you make sure my relative's care plan records all their needs, risks and the support staff must provide?
- 02How often are care plans and risk assessments reviewed, especially after a change in health or needs?
- 03How do you record the application of topical creams and check that these records are complete?
- 04If my relative wants to manage any medicines themselves, what formal safety assessment will you complete?
- 05Who is currently managing the home, and what support is being provided while the manager's registration application is progressed?
This was an unannounced inspection of all five key questions and the overall service; the report says the previous inspection was in July 2017 and records the changes found since then. This explanation was written from the published report of 5 December 2018 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 Broadoaks
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- October 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 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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