CQC report explained · a nursing home
What the CQC found at Broomcroft House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2018
Rated Good; inspectors found safe, kind and personalised care, with two minor medicines-record issues to check.
This was an unannounced inspection on 27 March 2018. Inspectors spoke with people living in the home, relatives, staff and managers. They reviewed care and staff records, watched care being delivered, and checked the building and equipment.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable training, respectful care, activities, personalised records and effective management checks.
There were two minor issues with medicines arrangements. Some medicine trolley wall attachments were a little loose, and some medicine administration records contained unsecured sheets. Managers agreed these would be dealt with.
Kind and respectful staff
Staff knew people well and supported them with patience, dignity and respect. Inspectors saw friendly interactions and reassurance for people who were anxious or confused.
“People and their relatives told us the staff were kind and caring. They were overwhelmingly positive in the comments they made.” from the report
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment files showed checks on identity, references, criminal records and professional registration where needed.
“There were sufficient numbers of staff employed to meet people's needs. Recruitment procedures made sure staff were of suitable character and background.” from the report
Personalised care
Care records described people's needs, preferences, social history and wishes. Records were reviewed and updated, and relatives were involved in care planning.
“The care records we looked at were personalised and gave the reader a clear picture of the person's needs and preferences.” from the report
Activities and community links
People had access to varied activities and therapies, including pet therapy, music, church services and visits from a local nursery school.
“There was a range of activities and therapies available to people living at Broomcroft House.” from the report
Active management oversight
The home regularly asked people, relatives and staff for their views. Managers used surveys, meetings and daily checks to identify and act on improvements.
“We saw the registered provider had a comprehensive quality audit and governance system in place.” from the report
Loose medicine trolley attachments
minorMedicine trollies were secured but their wall attachments were a little loose. A nurse was told and agreed this would be resolved.
“Medicine trollies were locked and secured to the wall, however these attachments required securing further as they were a little loose.” from the report
Unsecured medicine record sheets
minorSome sheets in medicine administration records were not secured and could have been lost or misplaced. The unit manager agreed to check all records.
“We did find there were unsecured charts in some of the MARs we looked at, which meant they could get lost or misplaced.” from the report
- 01Were the loose medicine trolley attachments secured, and when was this completed?
- 02Were all medicine administration records checked for unsecured sheets, and how is this checked now?
- 03How are staffing numbers reviewed when people's care needs or the number of residents changes?
- 04How are families involved in reviewing their relative's care records and preferences?
- 05Which activities and therapies are currently available, and how are people supported to take part?
This was an unannounced inspection covering all five CQC questions and the overall rating; the report does not describe a separate focused inspection or a comparison with an earlier rating. This explanation was written from the published report of 8 June 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.
What inspectors found, February 2017
Broomcroft House Care Home was rated Requires Improvement; inspectors found kind, responsive care, but concerns about PEG records, nutrition monitoring and management systems.
Inspectors visited the home without warning on 4 January 2017. They spoke with people living there, relatives, staff and the manager. They reviewed care plans, staff records and service monitoring records.
The home had improved since the previous inspection in March 2016. The earlier breaches had been addressed well enough to meet the regulations at this inspection. People and relatives generally said they felt safe and were positive about the improvements.
The main remaining issues were incomplete or unsuitable records for PEG feeding, incomplete food charts, staff appraisals that had not been completed and quality checks that needed to become more reliable. Caring and responsive care were rated Good. Safe, effective and well-led were rated Requires Improvement.
Kind and respectful care
Inspectors saw staff being compassionate, patient and respectful. People were clean, comfortable and well presented.
“We saw staff were very kind, compassionate and respectful to people.” from the report
Responsive care plans
Care plans recorded people's preferences, routines and wishes. They were reviewed when people's health or needs changed.
“Care plans seen contained information about the person's preferred name and identified the person's usual routine and how they would like their care and support to be delivered.” from the report
Staffing and recruitment
Inspectors found enough staff on duty to meet people's needs. Recruitment checks had been completed for the staff records reviewed.
“Staffing rotas showed there were consistently enough staff on duty to keep people safe.” from the report
Improvement since the previous inspection
The home had addressed the previous inspection's regulatory breaches well enough to meet the regulations at this visit.
“We found sufficient improvements had been made to meet regulations.” from the report
PEG feeding records
seriousThe medication record for PEG feeding did not require a finish time or hourly delivery record. Inspectors said this created a risk that feeding might not follow the prescription.
“This meant there was a risk of the PEG feeding not being administered as prescribed because either a finish time or hourly delivery was not required on the MAR.” from the report
Nutrition records
needs fixingFood charts were sometimes incomplete when completed by new agency staff. This meant there was a risk that people would not be fully supported to eat and drink enough.
“Food charts were sometimes incomplete by new agency staff. Therefore there is a risk people may not be sufficiently supported to eat and drink enough.” from the report
Management oversight
needs fixingThere was no registered manager at the time of the inspection. The new audit systems also needed to become more reliable and firmly established.
“There was no registered manager in place. New audit processes in place needed to be embedded and robust to ensure risks were identified and quickly rectified.” from the report
Safeguarding review
seriousThe local authority was still treating the home as a red risk while checking whether improvements would last. It was also investigating a new safeguarding alert.
“we are looking for sustainability and we have also had a new safeguarding alert in which we are investigating.” from the report
- 01How are PEG feed start times, finish times, water flushes and medicines recorded now?
- 02How do you check that food and fluid charts are completed correctly, including by agency staff?
- 03Has the manager completed CQC registration, and who is responsible for management while this is pending?
- 04Have all staff appraisals now been completed, and how are staff training and supervision monitored?
- 05What was the outcome of the safeguarding alert that was being investigated, and what changes followed it?
This was an unannounced inspection covering all five key questions and checking improvements made since the previous inspection in March 2016. This explanation was written from the published report of 11 February 2017 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 Broomcroft House Care Home
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- June 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 12 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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