CQC report explained · a residential care home
What the CQC found at Broadway Lodge Residential 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 were not assured that night staffing levels were enough for people's needs. Medicines and infection control were managed safely, but accident records and recruitment records were not always complete.
- Effective?
- Requires improvement
- This question was not rated in this focused inspection. Inspectors found that the home was working within the Mental Capacity Act, but some best-interest records did not show who had been involved in decisions.
- Caring?
- Good
- This question was not rated in this focused inspection. People were treated with respect, and staff promoted privacy, dignity and person-centred care.
- Responsive?
- Good
- This question was not rated in this focused inspection. People received support from regular staff who knew them well, and the manager sought feedback from people and relatives.
- Well-led?
- Requires improvement
- The provider's audits and governance systems did not identify important problems with staffing and records. The manager had introduced more audits and sought advice, but the provider remained in breach of good governance requirements.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found kind, respectful care but concerns about night staffing, records and oversight.
This was an unannounced focused inspection on 27 June 2023. Two inspectors spoke with five people and seven staff. They reviewed care, medicine, recruitment, accident and incident records, and management systems.
The home remained Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found medicines were managed safely, the home was clean, and people were treated with respect. However, they were not assured that night staffing was enough for people's needs.
The home had not fixed all the problems found at the previous inspection. Records about accidents, recruitment and best-interest decisions were incomplete or unclear. The systems used to check quality had failed to identify these problems.
Kind and respectful care
Staff promoted privacy and dignity and treated people with respect. People and relatives spoke positively about the staff team.
“People received their support from regular staff whom they knew well. Staff promoted person centred care, upheld privacy and dignity and treated people with respect.” from the report
Medicines managed safely
People received their medicines as prescribed. Staff had medicine training and regular checks of their competence.
“Medicines were managed safely. People received their medicines as prescribed.” from the report
Mental capacity safeguards
The home was working within the principles of the Mental Capacity Act. Required legal authorisations were in place where people were deprived of their liberty.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Positive relationships
People said they were happy with the home. The manager was visible and interacted with people in a friendly way.
“People and relatives spoke positively about the management and staff team.” from the report
Night staffing
seriousThere was no system for calculating the staffing needed at night. One staff member was supporting 17 people on a night shift, including people who needed position changes using equipment.
“At the time of the inspection one member of staff was working on a night to support 17 people.” from the report
Incomplete accident records
needs fixingAccident and incident records did not always explain what staff had done or what was needed to prevent the problem happening again. Audits also missed incidents.
“Accidents and incidents were recorded. However, records did not always detail the action taken by staff to support people following an accident or incident.” from the report
Weak oversight
seriousThe provider's checks did not find the problems with staffing and records. This was a continued breach of the good governance regulation.
“Shortfalls remained regarding systems and processes to manage the quality of the service.” from the report
Best-interest records
needs fixingSome records did not show that best-interest decisions had been discussed with the relevant people.
“The records relating to best interest decisions did not always contain appropriate information to show decisions had been discussed with the relevant people.” from the report
- 01How many staff will be working on each night shift, and how do you calculate whether this is enough for my relative's needs?
- 02What changes have you made to ensure accidents and incidents are recorded fully and reviewed for lessons?
- 03How are you checking that recruitment records contain all required information?
- 04How will you show that relevant people are involved in best-interest decisions?
- 05What action has been taken in response to the Regulation 17 breach and the CQC action plan?
This was a focused inspection checking the previous Warning Notice and looking at Safe, including infection control, and Well-led; the other key questions were not rated in this report. This explanation was written from the published report of 5 December 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, October 2022
Requires Improvement; inspectors found kind care and enough staff, but important risks and poor record-keeping were not managed well.
This was a focused inspection on 28 April and 10 May 2022. The inspector spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home remained Requires Improvement overall, as it was at the previous inspection. Safe and Well-led were both rated Requires Improvement. Inspectors found people were treated kindly, felt safe, and there were enough staff, but some care plans and risk assessments lacked important information.
The home was still in breach of Regulation 12 for safe care and treatment and Regulation 17 for good governance. The provider completed some actions during or after the inspection, including putting emergency evacuation plans in place and arranging legionella testing, but CQC issued a warning notice about governance.
Kind staff
People and relatives spoke positively about the staff team. Staff knew people well and treated them with kindness and compassion.
“People and relatives spoke positively about the kind nature of the staff team.” from the report
Enough staff
Inspectors found there were enough staff to meet people's needs. Staff worked calmly and had time to spend with people.
“There were enough staff to meet people's needs in a timely manner.” from the report
Infection control
The home had improved its infection prevention and control arrangements and was no longer in breach of the relevant part of Regulation 12.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12. (3)” from the report
Safe recruitment
Required recruitment checks had been completed and recorded consistently before staff started work.
“All required checks had been undertaken prior to staff commencing employment and consistently recorded.” from the report
Risks not consistently managed
seriousSome people's health risks, weight loss risks and environmental risks were not properly addressed. Emergency evacuation plans were missing for some people when inspectors visited.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service” from the report
Medicine instructions
needs fixingInstructions for medicines given when needed were not always accurate or clear enough for staff.
“Protocols for 'as and when' required medication were in place, however these were not always correct” from the report
- 01How are health conditions and risks such as weight loss recorded, reviewed and acted on now?
- 02Are personal emergency evacuation plans in place and up to date for every resident?
- 03What checks are now made on bed rails and legionella risks, and how are the results recorded?
- 04How do you make sure care plans and risk assessments are reviewed in line with your policy?
- 05What changes have been made since the warning notice to improve audits, records and management oversight?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 11 October 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 Lodge Residential Home
5 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Broadway Lodge Residential Home →
- October 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Broadway Lodge Residential Home →
- March 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2014GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 21 December 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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