CQC report explained · a nursing home
What the CQC found at Broomhill Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The home was not always safe. Inspectors found problems with PPE use, visitor records and one risk record, although medicines, staffing, safeguarding and incident management were generally satisfactory.
- Effective?
- Requires improvement
- This key question was not inspected at this visit. Its rating from the previous comprehensive inspection was used.
- Caring?
- Requires improvement
- This key question was not inspected at this visit. Its rating from the previous comprehensive inspection was used.
- Responsive?
- Requires improvement
- This key question was not inspected at this visit. Its rating from the previous comprehensive inspection was used.
- Well-led?
- Good
- The home had improved its leadership and monitoring systems. Inspectors found a more person-centred culture, better staff support and stronger quality checks.
What inspectors found, April 2021
Requires Improvement; inspectors found improvements in care planning, medicines and leadership, but infection control and some risk records still needed attention.
This was an unannounced, planned inspection. Two inspectors spoke with people using the home, staff, managers and a health professional. They reviewed care plans, risk assessments, medicine records, policies and audits.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement because staff did not always use PPE correctly, visitor checks were not always recorded, and one risk record needed more detail. Medicines were managed safely and there were enough staff.
Well-led was rated Good. The home had improved since the previous inspection. Care planning, quality checks, staff support and learning from incidents were stronger. The home was no longer in breach of the regulations identified at the last inspection.
Only Safe and Well-led were inspected at this visit. The other key question ratings from the previous comprehensive inspection were used in the overall rating.
Safer medicines
Medicines were organised and administered safely. Records and daily checks helped confirm that people received medicines as prescribed.
“People's medicines were now managed in a safe way. Medicines systems were organised, and there were safe protocols for the receipt, storage, administration and disposal of medicines.” from the report
Care planning
New care plans recorded people's needs, preferences and interests. Staff generally understood how to support people safely, including people with complex behaviour.
“New care plans had been developed and recorded people's needs, preferences and interests. Staff understood how people wanted to receive support and respected their decisions.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. Recruitment checks had been completed and some people had individual staff support.
“There were sufficient numbers of staff available to meet people's needs. Some people had individual staff support to ensure their safety and staff understood their responsibilities.” from the report
Improved leadership
The management team had introduced quality checks, action plans and regular staff meetings. Leaders worked with health and social care professionals to improve the service.
“The registered manager had now developed systems to monitor the quality and safety of the service provided.” from the report
PPE was not always used correctly
needs fixingNot all staff wore PPE safely and effectively during the inspection. The home reviewed its PPE arrangements after inspectors raised this.
“We found not all the staff wore PPE effectively and safely when working in the home, including not wearing a face mask and touching their masks.” from the report
Visitor checks were not always recorded
needs fixingRecords of visitors' temperature checks and health declarations were not always easy to find or complete. The system was reviewed after the inspection.
“Improvements were needed to ensure necessary checks were recorded when visitors entered the home.” from the report
One risk plan needed more detail
needs fixingOne person's plan did not give enough detail about support during personal care. The manager took immediate action after this was discussed.
“However, one record needed further review to ensure staff understood how to provide support when assisting with personal care.” from the report
- 01What checks are now used to make sure every staff member wears PPE correctly and safely?
- 02How are visitors' temperature checks and health declarations recorded and checked?
- 03What changes were made to the risk plan covering support with personal care?
- 04How do daily medicines audits identify and correct any missed or incorrectly recorded medicines?
- 05How will you show that the improvements identified in the ongoing action plan have been completed?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 17 April 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.
What inspectors found, July 2019
Broomhill Care Centre was rated Requires Improvement; inspectors found unsafe medicines management, incomplete care plans and inconsistent person-centred care.
This was the home’s first CQC inspection. It was an unannounced, comprehensive inspection on 21 May 2019. The inspector spoke with people, staff and other professionals, observed care, and checked care records, staff files and management information.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found risks were not always recorded clearly, medicines were not always managed safely, and care plans did not always contain enough detail.
There were also positive findings. People said they felt safe and enjoyed the food. Staff were generally kind, enough staff were available during the visit, people could access healthcare, and privacy and dignity were usually maintained. However, the home was using many agency staff and was still recruiting.
The provider was in breach of Regulations 9, 12 and 17. CQC required the provider to send a report explaining what action it would take, and said it would monitor the home through information received.
Safeguarding systems
The home had safeguarding systems, and staff knew what action to take if they were concerned about abuse. Concerns had been referred to the appropriate authorities when needed.
“The provider had systems in place to safeguard people from the risk of abuse.” from the report
Staffing and recruitment
Inspectors found enough staff during the visit to meet people's needs. Recruitment checks included references and Disclosure and Barring Service checks.
“We spent time observing staff interacting with people who used the service. We found there were enough staff to assist people.” from the report
Healthcare support
People could access healthcare professionals when needed, and staff followed the advice recorded in care plans.
“We looked at care plans and saw that when healthcare advice had been given, staff had followed it to ensure people were supported appropriately.” from the report
Privacy and dignity
Staff knocked before entering rooms and spoke discreetly about care. Records were stored safely to protect confidentiality.
“We observed staff knocking on doors prior to entering and talking to people discreetly about care interventions.” from the report
People could raise concerns
A complaints procedure was available, and people told inspectors they felt able to complain if needed. People and relatives were also invited to meetings about improvements.
“People we spoke with told us they liked living at the service.” from the report
Risk information was incomplete
seriousRisk assessments did not always explain how to support people safely. This included missing information about sling use, bed rails and emergency evacuation.
“Risk assessments in place did not contain enough detail to ensure people were supported safely and risks minimised.” from the report
Medicines records were unreliable
seriousSome medicine administration records were not signed, stock totals were missing and storage temperatures were not always recorded. One eye drop bottle had remained in use beyond the recommended period.
“People's medicines were not always managed in a safe way.” from the report
Care was not always personalised
seriousCare plans did not always contain enough detail about people's needs, choices and preferences. This could make consistent care more difficult, particularly with many agency staff working in the home.
“People did not always receive person-centred care which met their needs and preferences.” from the report
Training gaps
needs fixingStaff had completed mandatory training but had not received dementia care training. They had also not received end-of-life care training, although nobody needed end-of-life care during the inspection.
“For example, the service provided support for people living with dementia, but staff had not received training in this area.” from the report
Few meaningful activities
needs fixingNo meaningful activities took place during the inspection. The activity co-ordinator was covering a support worker role because of staffing shortages.
“No meaningful activities took place during our inspection.” from the report
Quality checks did not lead to action
seriousAudits had identified some problems, but these were not always dealt with. Other concerns found by inspectors had not been identified by the audit system.
“Actions raised as part of the audit process were recorded but not always actioned by the provider.” from the report
- 01What changes have you made to medicines checks and records since the inspection?
- 02How do you now record individual moving and handling needs, including the correct sling and loop configuration?
- 03How many agency staff are currently working here, and has the staffing team become more stable?
- 04Have staff completed dementia care and end-of-life care training?
- 05What meaningful activities are now available, and how are they matched to each person's interests?
This was an unannounced comprehensive inspection covering all five CQC questions and both the premises and care provided. This explanation was written from the published report of 2 July 2019 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 Broomhill Care Centre
2 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- April 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- July 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2018
Registered with the Care Quality Commission on 5 June 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.
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
62 live-in carers within about an hour of Derbyshire
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 £1,010 to £1,260 a week. 51 can care for a couple. 12 years' experience on average.
“Ernest is an amazing professional carer who delivers care from the heart.”
“We particularly appreciate the companionship Dawn gives in the evenings when she plays cards and Scrabble with my mother.”
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.