CQC report explained · a nursing home
What the CQC found at Broome Park Nursing 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
- Risks were not always properly assessed or managed. Inspectors found problems with choking guidance, food and fluid records, a pressure-relieving mattress, medicine guidance and medicine storage.
- Effective?
- Requires improvement
- Some people waited up to an hour for lunch, and communication with health professionals was often poor. Staff had training and people were supported to access healthcare.
- Caring?
- Requires improvement
- People were not always treated with dignity and respect. Inspectors saw limited interaction during one person's care, and one bedroom did not provide enough privacy.
- Responsive?
- Requires improvement
- Care plans were not always detailed or personalised, and some people lacked meaningful activities and end of life planning. A new activity planner led to improvement during the second visit.
- Well-led?
- Requires improvement
- Quality checks had not found or corrected important problems. Communication with relatives and professionals was poor, and there was no registered manager in post at the time of inspection.
What inspectors found, December 2022
Broome Park Nursing Home was rated Requires Improvement, with risks in care, medicines, dignity, personalised support and management.
Inspectors made two unannounced visits on 17 and 26 August 2022. They spoke with people, relatives, staff and health professionals. They observed care and checked care, medicine and recruitment records.
All five areas were rated Requires Improvement. Inspectors found unsafe risk management, incomplete records, medicine storage problems and heavy use of agency staff. Some people waited a long time for meals and did not have enough meaningful activities.
There were also positive findings. People said they generally felt safe and staff were kind. Staff received training, people could access health services, and improvements were made during or after the inspection.
The previous overall rating was Good, published in March 2021. The provider was told to produce an action plan, and CQC issued a Warning Notice for failures in governance.
People felt safe
People told inspectors they generally felt safe in the home. Staff knew how to recognise and report abuse.
“People told us they felt safe living at Broome Park.” from the report
Staff training
Staff had induction and regular training. Their medicine competence was checked by the manager.
“Staff had received relevant training before they were able to give people their medicines.” from the report
Healthcare support
People were supported to see healthcare professionals when needed. Oral health was assessed and supported.
“People were supported to access healthcare services when they needed to.” from the report
Communication support
Care plans included support such as picture cards and prompts. Staff supporting people who used Makaton understood these signs.
“People's communication needs were met.” from the report
Changes to activities
After inspectors raised concerns about a lack of stimulation, the home introduced a new activity planner and staff saw more activities on the second visit.
“A new activity planner had been put in place and on our second visit to the service, we observed an improvement in activities available to people” from the report
Risks and medicines
seriousRisk assessments and care instructions were incomplete or not followed. Inspectors also found medicines stored above the recommended temperature and missing guidance for a medicine given when needed.
“Risks to people were not always safely managed.” from the report
Agency staffing
needs fixingThe home relied heavily on agency staff. Inspectors and professionals said this meant staff did not always know people's needs well.
“The service was heavily reliant on agency staff which meant that people often did not get to know the staff supporting them.” from the report
Dignity and privacy
seriousSome staff did not always know people's names or explain care. One bedroom had an uncovered opening to a communal area, reducing privacy.
“Failure to treat people with dignity and respect was a breach of Regulation 10(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Personalised care
needs fixingSome care plans did not record personal preferences. Some people had little structure or meaningful activity, and not everyone had an end of life care plan.
“Care plans were not always detailed and personalised.” from the report
Poor oversight and communication
seriousManagement checks did not identify key problems. Relatives and professionals reported poor communication, and there were no regular residents' meetings.
“Quality monitoring systems at the service were not effective.” from the report
Late meal
needs fixingPeople in one part of the home waited up to an hour for lunch because meals were delayed from the kitchen.
“In Stable Cottage people were waiting in the dining room for up to one hour for lunch due to a delay in transporting the meals over from the kitchen in the main house.” from the report
- 01What has changed to make sure speech and language therapy advice about food and drink is always followed?
- 02How are you reducing the use of agency staff, and how do you make sure temporary staff know my relative's needs?
- 03How will you make sure care plans record personal preferences, daily structure and end of life wishes?
- 04How are medicine temperatures and medicines given when needed now checked?
- 05How can relatives receive regular updates and take part in care planning?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control; it also checked the care home premises and care provided. This explanation was written from the published report of 9 December 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.
What inspectors found, March 2021
Broome Park Nursing Home rated Good; inspectors found improvements, but essential fire safety work was still underway.
This was an unannounced focused inspection on 27 January 2021. Inspectors looked at safe, effective and well-led care. They spoke with people, relatives, staff and a visiting GP, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good overall and Good for Safe, Effective and Well-led. Inspectors found better risk management, medicines records, staff support, food and drink monitoring, consent records and management checks. People said they felt safe, and inspectors found strong infection control arrangements.
The inspection followed concerns about fire safety and safeguarding. Essential fire safety work had been delayed, and an enforcement notice had been issued by Surrey Fire and Rescue Service. The work had started when inspectors visited and was expected to be completed by April 2021. The home had previously been rated Requires Improvement in December 2019 and was no longer breaching regulations at this inspection.
Care records and risk planning
Care plans were linked to risk assessments, and staff followed guidance about people's individual needs, including food textures.
“People's care plans were linked to risk assessments that outlined the action needed by staff to keep people safe.” from the report
Medicines
Medicines were stored securely, records were checked, and staff were trained and assessed before giving medicines.
“Systems and processes for the management of people's medicines were robust.” from the report
Food and drink
Mealtimes were calmer and better organised than at the previous inspection. Required food and fluid monitoring was completed without the earlier gaps.
“People were served their meals quickly, so they were not having to sit and wait for a long time as they had done previously.” from the report
Consent and legal rights
Mental capacity assessments, best-interest decisions and applications relating to restrictions on liberty were documented correctly.
“People's legal rights were being protected as the correct legal documentation was now being completed.” from the report
Fire safety work was unfinished
seriousEssential fire safety work had been delayed and an enforcement notice had been issued before the inspection. The work had started but was expected to finish by April 2021.
“There had been a delay in undertaking necessary fire safety work on the building which had led to an enforcement notice being issued by Surrey Fire and Rescue Service prior to the inspection.” from the report
Worn surfaces and flooring
needs fixingInspectors said some parts of the interior needed redecoration and that worn surfaces and flooring could make effective cleaning more difficult. The provider said plans were being made to improve this.
“the interior looked as if it could benefit from redecoration and some worn surfaces and flooring that could pose a challenge for effective cleaning.” from the report
- 01Has all the fire safety work identified in the report been completed, including the fire doors and fire alarm system?
- 02What action has been taken about the worn surfaces and flooring, and when will this work be finished?
- 03How are food and fluid records checked now to make sure there are no gaps?
- 04How are medicine records audited and staff competency checked?
- 05How will relatives be kept informed about infection control and visiting arrangements?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 10 March 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 Broome Park Nursing Home
3 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2021Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- December 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2018
Registered with the Care Quality Commission on 14 September 2018.
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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