CQC report explained · a nursing home
What the CQC found at Broadway Halls 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
- Medicines were not always managed safely. Inspectors also found that risks linked to pressure sores, thickening powder and recruitment records needed improvement.
- Effective?
- Good
- People's needs were assessed and care plans were in place. Staff worked with health professionals and supported people to make choices and give consent.
- Caring?
- Good
- This key question was not inspected during this focused inspection.
- Responsive?
- Good
- This key question was not inspected during this focused inspection.
- Well-led?
- Requires improvement
- The home's quality checks did not always identify or resolve problems, including medicines issues and low fluid intake. The manager had an action plan and was working with commissioners.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found concerns about medicines, pressure sore prevention, staffing and checks on the quality of care.
This was an unannounced focused inspection on 8 and 9 September 2022. Inspectors spoke with people, relatives and staff. They reviewed care records, medicines records, recruitment files and management records.
The home was not always safe. Medicines records had unexplained gaps, some storage checks were missing, and risks linked to pressure sores were not always managed consistently. Recruitment checks also needed improvement.
The home was rated Good for Effective. People received support from health professionals, staff sought consent and care was planned around people's needs. However, the home was rated Requires Improvement for Safe and Well-led because its checks did not always identify or fix problems.
The previous overall rating was Good, published in May 2019. This inspection did not assess Caring or Responsive, so those areas were not given new ratings.
People felt safe
People and relatives said they felt safe. Staff knew how to recognise and report possible abuse.
“People felt safe living at the home, and their relatives were confident in their loved ones' safety.” from the report
Support from other services
Staff worked with health and social care professionals. Records showed involvement from several outside services.
“Staff worked with other agencies to ensure people received a joined-up approach to their care.” from the report
Consent and choice
Staff asked for consent and offered choices. Care plans recorded relevant legal authorisations.
“We observed staff offering people choices and gaining their consent before carrying out tasks.” from the report
Open communication
Relatives said they were informed when things went wrong. Staff described the management team as approachable and supportive.
“Relatives told us they were informed when things went wrong.” from the report
Action plan
The manager had an action plan covering responsibilities, deadlines and progress, and was working with commissioners.
“This action plan outlined who was responsible for completing each action, the target completion date and progress made to date.” from the report
Medicines records and storage
seriousThere were unexplained gaps in medicines administration records and stock balances were not always accurate. Medicine fridge temperatures were also not consistently recorded.
“Several people's medicines administration records (MAR) contained unexplained gaps in recording.” from the report
Pressure sore prevention
seriousAt least one person needed regular repositioning, but support to reduce the risk of pressure sores was not always consistent.
“People had not always received consistent support to reduce their risk of pressure sores.” from the report
Staffing and recruitment
needs fixingPeople, relatives and staff raised concerns about staffing levels. Employment gaps for five staff had not been explored.
“We found gaps in the employment histories of five members of staff had not been explored with them.” from the report
Management checks
seriousThe home's audits did not always identify or act on important problems, including medicines concerns and low fluid intake.
“The provider's quality assurance systems and processes were not effective and had not enabled them to assess, monitor and improve the quality and safety of the service.” from the report
Food and drinks
minorPeople gave negative feedback about the food. When fluid targets were missed, records did not always show what action had been taken.
“People provided negative feedback about the food.” from the report
- 01What action has been taken to stop unexplained gaps in medicines administration records?
- 02How are medicine fridge temperatures and PEG feed storage temperatures now checked and recorded?
- 03How do you make sure people at risk of pressure sores are repositioned consistently?
- 04What has changed in staffing levels since the inspection, especially at night and on the nursing floor?
- 05How do your current audits identify and act on missed fluid targets and other care risks?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over when the overall rating was calculated. This explanation was written from the published report of 29 February 2024 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, February 2022
Broadway Halls Care Home was inspected but not rated; inspectors were assured about infection prevention and control measures.
This was a targeted inspection about infection prevention and control during COVID-19. Inspectors also asked about staffing pressures and whether these affected care. The inspection was announced with one day's notice.
Inspectors found good arrangements for visitors, including testing, handwashing, booking visits and protective equipment. The home also used extra cleaning, visiting areas and a separate visiting pod to help families keep in touch.
Inspectors were assured that the home was managing infection risks, PPE, testing, admissions, outbreaks and visits in line with guidance. The Safe question was inspected but not rated, and the other four questions were not examined in this inspection.
Safe visiting arrangements
The home used several ways to help families stay in contact, including booked visits and a separate visiting pod.
“The service had a separate visiting pod for relatives and friends which enabled them to see their loved ones safely.” from the report
Protective equipment
Staff followed PPE guidance and supplies were available close to residents' bedrooms.
“Staff adhered to PPE guidance and practices. There was a plentiful supply of PPE at all PPE stations situated close to people's bedrooms.” from the report
Infection controls
Inspectors were assured that the home was using testing, cleaning, hygiene and other measures to reduce infection risks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01How are staffing pressures affecting residents and the care they receive now?
- 02What infection prevention measures are currently in place for visitors and professional visitors?
- 03How will family visits be arranged if COVID-19 risks or restrictions change?
- 04How does the home make sure PPE supplies remain available near residents' bedrooms?
- 05When were the other four CQC questions last inspected, and what were their ratings?
This was a targeted inspection of infection prevention and control and staffing pressures within Safe; it did not update the overall rating or assess Effective, Caring, Responsive or Well-led. This explanation was written from the published report of 3 February 2022 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 Broadway Halls Care Home
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2014Inspected but not rated
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 30 November 2010.
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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