CQC report explained · a nursing home
What the CQC found at Broomgrove Trust Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2022
Broomgrove Trust Nursing Home was rated Requires Improvement; inspectors found kind care but concerns about staffing, training and management records.
Inspectors visited without notice on 15 September 2022 and completed inspection activity on 16 September 2022. They spoke with people, relatives and staff, observed care, and checked care records, medicines, training, recruitment and quality checks.
The home was not always safe. There were delays answering call bells, and inspectors found there were not always enough suitably skilled staff. Training records had large gaps, so managers could not be sure staff had current health and safety training.
The home's management systems were not always effective. Some care records contained out-of-date or conflicting information, and some policies had not been reviewed for several years. However, medicines were managed safely, infection control was good, staff were recruited safely, and people and relatives described staff as kind and caring.
The overall rating changed from Good at the previous inspection to Requires Improvement. This inspection rated only Safe and Well-led. The other key question ratings were not inspected and the report says the overall rating used previous ratings for those areas.
Medicines
Inspectors found that medicines were ordered, stored, given and recorded safely. Staff handling medicines had been trained and assessed as competent.
“People received their medicines safely and as prescribed.” from the report
Infection control
Inspectors were assured that the home used protective equipment safely, kept the premises hygienic and had arrangements to prevent and manage infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Kind care
People and relatives described staff as kind and caring. Inspectors saw staff respond respectfully, offer reassurance and treat people with warmth.
“We observed positive interactions between people and staff.” from the report
Safe recruitment
Recruitment records contained the background checks needed to assess whether new staff were suitable to work with vulnerable people.
“Staff were recruited safely.” from the report
Health partnerships
The home worked with health and social care professionals, including regular visits from a GP and support with health appointments.
“The home had effective relationships with health and social care professionals and services.” from the report
Staffing and call bell delays
seriousThere were not always enough staff to meet people's needs promptly. Inspectors saw three call bells unanswered within five minutes, with one taking over ten minutes to answer.
“Three calls bells were not answered within five minutes and staff took over ten minutes to answer one call bell.” from the report
Gaps in staff training records
seriousTraining records had gaps of up to four years for some medicines and health and safety training. Managers could not be confident that all staff had current training relevant to their roles.
“There were significant gaps in the providers training matrix.” from the report
Inconsistent care records
needs fixingSome care plans and capacity records were out of date or conflicted with other information. This created a risk that people might not receive the right care or support.
“Reviews and updates of care plans had been transferred in part but had resulted in some information being out of date, conflicting, and could put people at risk of poor care and support.” from the report
Weak oversight
needs fixingThe systems used to monitor quality and staffing concerns had not worked effectively. Some policies had not been reviewed since 2019, and the staffing dependency tool was incomplete and not being used.
“The provider had failed to monitor staff call times and act on some concerns.” from the report
Missing risk assessment
needs fixingOne person's records did not contain a bed rails risk assessment at the time of inspection. The manager said risk assessments were being reviewed as part of the new care plan format.
“We did find a bed rails risk assessment was missing in one person's care records.” from the report
- 01How many staff are on duty for each shift now, and how do you match staffing to each person's needs?
- 02How do you monitor call bell response times, and what were the recent results?
- 03How do you make sure every staff member is up to date with medicines, health and safety and other required training?
- 04Which care plans and capacity assessments have been checked since the inspection, and how do you prevent conflicting information?
- 05Have all policies been reviewed and has the staffing dependency tool been completed and put into use?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 19 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.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with some records needing prompt updating.
This was an unannounced planned re-inspection on 10 February 2020. Inspectors spoke with people living at the home, relatives, staff and visiting professionals. They observed care and reviewed care, medicine, recruitment and management records.
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, kind care, good activities and effective management.
There were two record-keeping issues. Some care files had conflicting or incomplete information, and there were no records showing that creams had been applied as prescribed. The home dealt with both issues immediately after, or on the day of, the inspection.
Kind and respectful care
Inspectors saw staff treating people with compassion and kindness. Privacy, dignity and independence were promoted.
“People were seen to be treated with compassion and kindness.” from the report
Safe staffing and recruitment
Staffing levels were sufficient for people's needs and recruitment checks were described as robust.
“There were sufficient staff on duty to meet people's needs.” from the report
Personalised support
People's choices and preferences were recorded and followed. Staff responded promptly when people needed help.
“Care was person-centred, and people's choices and preferences were documented and adhered to.” from the report
Activities and relationships
People were supported to maintain family relationships and take part in a wide range of activities and outings.
“Three activities staff organised a wide range of outings, activities and occupations.” from the report
Good oversight
The home used audits, meetings and incident reviews to identify learning and improve care.
“Systems were in place to inform learning and improvement of service provision.” from the report
Cream application records
needs fixingCare staff applied creams, but there were no topical medicines administration records. This meant the home could not show that creams were applied as prescribed. New records were available by the end of the inspection day.
“This meant there was no evidence creams were being applied as prescribed.” from the report
Incomplete care records
minorSome care files contained conflicting or incomplete information. The home addressed this immediately after the inspection and supplied evidence of updated files.
“Care files included health and personal information, though some contained conflicting or incomplete information.” from the report
- 01How are topical creams recorded now, and who checks that the records are complete?
- 02What changes were made to the care files that contained conflicting or incomplete information?
- 03How will you make sure care records remain accurate and up to date?
- 04How are staffing levels adjusted when people's dependency needs change?
- 05How are complaints, falls, accidents and medicines errors reviewed and acted on?
This was an unannounced re-inspection covering the home, the care provided and all five CQC questions; an April 2019 report had been withdrawn because of an issue with some information gathered. This explanation was written from the published report of 18 March 2020 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 Broomgrove Trust Nursing Home
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Broomgrove Trust Nursing Home →
- March 2020Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Broomgrove Trust Nursing Home →
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
90 live-in carers within about an hour of Sheffield
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,270 a week. 76 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Beatrice was a talent dementia carer whose professionalism and dedication allowed mums wishes to remain in her own her come true.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.