CQC report explained · a residential care home
What the CQC found at Broxbourne House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines systems, suitable risk assessments and effective infection control.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff were trained and supported, and people received help with food, healthcare, communication and decisions about their care.
- Caring?
- Good
- This area was not assessed during this focused inspection.
- Responsive?
- Good
- This area was not assessed during this focused inspection.
- Well-led?
- Good
- The home had clear management arrangements, regular checks on quality and a culture of openness, learning and improvement.
What inspectors found, March 2023
Broxbourne House is rated Good; inspectors found safe, effective and well-led care.
The inspection was unannounced and took place on 24 February 2023. One inspector spoke with three people and four staff. They reviewed care records, medicines records, recruitment files and checks on how the home was run.
Inspectors found people were happy and felt safe. Staff knew people's needs, treated them kindly and supported their choices and independence. There were enough trained staff, medicines were handled safely, and the home was clean and suitable for people's needs.
This was a focused inspection of Safe, Effective and Well-led. All three areas were rated Good. Caring and Responsive were not assessed during this visit. The overall rating improved from Requires Improvement at the previous inspection.
Kind, individual care
People said staff were kind, knew them well and supported their choices and independence. Care plans were individualised and person centred.
“People were happy living at Broxbourne House. They told us staff were kind towards them and knew their needs well.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs. Staff had relevant training, supervision and checks of their competence.
“People and staff told us there were sufficient numbers of staff to meet people's needs.” from the report
Safe medicines
Medicines were stored securely and records and audits were in place. Staff who gave medicines had suitable training and competency checks.
“People received their medicines safely.” from the report
Visible management
The management team was described as approachable and supportive. Audits covered medicines, infection control, accidents, incidents and care plans.
“There were robust quality assurance processes in place which were carried out by the registered manager.” from the report
Some updating still needed
minorThe home had an ongoing programme of decoration and refurbishment. Some flooring had been identified as needing an update.
“The provider had an ongoing programme of decoration and refurbishment for areas identified as requiring updating, for example, some areas of flooring.” from the report
- 01What decoration or flooring work is still outstanding, and when will it be completed?
- 02How will you make sure my relative's care plan is reviewed as their needs change?
- 03How do you check that staff remain competent to give medicines and use moving equipment?
- 04How are people and relatives involved in decisions about the home and their care?
- 05How will you monitor the areas not assessed in this inspection, especially Caring and Responsive?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and the overall rating changed from Requires Improvement to Good based on this inspection. This explanation was written from the published report of 7 March 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, February 2021
Broxbourne House rated Requires Improvement; inspectors found safe care, but leadership and quality checks were not yet fully embedded.
Inspectors made an unannounced visit on 13 January 2021. They spoke with three people using the home, two care staff, the provider and a domestic assistant. They reviewed care records, medicines records and records about how the home was run.
The home was rated Good for Safe. Inspectors found that risks, medicines, staffing, recruitment and infection control were generally managed safely. They also found that earlier concerns about safe care and treatment were not supported by evidence during this inspection.
The home was rated Requires Improvement for Well-led. A new manager had been recruited but had not started. Quality checks were in place, but some audits were not up to date or detailed enough, and accidents and incidents had not recently been analysed for lessons.
The overall rating remained Requires Improvement, as it had been at the previous inspection. Safe improved from Requires Improvement to Good, while Well-led stayed at Requires Improvement.
Improved safety rating
Safe improved from Requires Improvement at the previous inspection to Good at this inspection.
“At this inspection this key question has now improved to Good.” from the report
Medicines management
Inspectors found that medicines were given as prescribed, with clear records, stock checks, audits and staff competency checks.
“Systems and processes were in place to ensure medicines were managed safely.” from the report
Staffing and recruitment
There were enough staff to support people, including consistent agency staff when COVID-19 caused staff absences. Recruitment checks were in place.
“Staffing levels were sufficient to support people's needs with additional consistent agency staff deployed where there had been staff absence due to the COVID-19 outbreak.” from the report
Safeguarding
Staff understood how to recognise and report possible abuse, and serious concerns were referred to the local safeguarding team when needed.
“Staff understood how to recognise, and report concerns if they thought a person may be at risk of harm.” from the report
Respect and dignity
The report says people's human rights were respected and their dignity was maintained during personal care.
“The provider ensured people's human rights were respected and their dignity in their personal care routines was maintained.” from the report
Leadership was still changing
needs fixingA new manager had been recruited but was not yet in post. The home was being supported by an interim manager and the provider.
“A new manager had been recruited but was not yet in post.” from the report
Quality checks were incomplete
needs fixingSome audits were not fully up to date, rigorous or detailed. The provider said this would be addressed when the new manager started.
“Quality assurance systems were in place but there had been some disruption to the completion of audits due to the COVID-19 outbreak putting additional strain on running the home.” from the report
Limited learning from incidents
needs fixingAccidents and incidents had not recently been analysed to identify lessons learned.
“Accidents and incidents had not been recently analysed to identify lessons learned.” from the report
Communal-area distancing
needs fixingInspectors were only somewhat assured that shielding and social distancing rules were being met. The building layout and chair positions made distancing difficult.
“Social distancing in communal areas was difficult to achieve due to the layout of the building and the positioning of people's chairs.” from the report
- 01Is the new manager now in post and registered with the CQC?
- 02Which audits were not up to date at the inspection, and what has been done to make them more rigorous and detailed?
- 03How are accidents and incidents now reviewed so that lessons are identified and acted on?
- 04What changes have been made to improve social distancing in communal areas?
- 05How are relatives being kept informed while visits or face-to-face meetings are restricted?
This was a follow-up inspection of specific concerns about safe care and treatment and the management of the home, with findings reported for Safe and Well-led; the other key questions were not separately rated. This explanation was written from the published report of 24 February 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 Broxbourne House
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- November 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2020Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: InadequateResponsive: InadequateWell-led: Inadequate
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 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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