Broadway Nursing

Broadway Nursing is a care home providing personal and nursing care to 41 people living with different health needs, including dementia, at the time of the inspection. The service can support up to 48 people in one adapted, single-floor building.

People’s experience of using this service and what we found

People living at Broadway Nursing and their relatives told us that their experience of using the service was overall positive. Staff planning and deployment to ensure people’s needs were met could at times be improved. We made a recommendation regarding this, as well as staff support through supervision and training, which the registered manager was addressing. The service environment and people’s medicines were overall managed safely, however we identified some improvement needs.

Since the last inspection, the service had introduced new electronic care plans. In a short period of time, staff had transferred existing knowledge of people onto the new documents. These provided rich and detailed information which showed particularly good person-centred knowledge and care. One person told us, “They are not intrusive, but they also always make sure I am ok. They have given me confidence again, which at this stage in my life I think is quite important.”

People, relatives and staff were involved in the development of the service. We heard about a family-like atmosphere. An overall long-standing staff team ensured not just people living at the service were looked after, but their relatives as well. Staff were honest that the new electronic system was a big change for them and not everyone was sure about its benefits. However, staff, along with people and relatives, were also complimentary about the ongoing and reliable support from the well-respected registered manager.

We found that through external learning opportunities the registered manager had developed their confidence and creativity in supporting the team in different ways. They also worked in partnership with a variety of health and social care professionals to achieve positive outcomes for people. This included the registered manager leading a particular project on ensuring good hydration for people. The service listened to people’s thoughts around the food and made changes to achieve continuous improvement. People’s specialist diets, including faith-based requirements, were catered for well.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

A new care quality manager was working closely with the registered manager to continuously develop a clearly changing service. Staff were honest about the pressures of their work, but also praised the overall positive, hardworking team morale. This was evident in the improvements that had been achieved, resulting in the service’s first overall good rating

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 30 January 2019). At the last the provider was in breach of regulations regarding safe care and treatment. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Broadway Nursing is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is situated in the Clubmoor area of Liverpool, close to shops, as well as public transport and can accommodate up to 48 people. There were 39 people living at the service when we visited.

At the last inspection on 5 March 2018 we found four breaches of regulations and we asked the provider to take action to make improvements to the safety of the premises, the frequency of staff supervision, promoting people’s dignity and the governance of the service. Following that inspection, the provider sent us an action plan of how they planned to rectify the breaches we found. At this inspection we found their action plan had been followed and three of the breaches had been rectified but further improvements were needed.

At this inspection we found a continued breach of Regulation 12, as doors to rooms containing hazardous items had locks on them, but these had not been used effectively, which put people at risk.

You can see what action we told the provider to take at the end of the full report.

The provider had rectified other aspects of the safety of people’s care and treatment, which had previously been in breach of regulations. The provider had identified further measures to make the environment safer for people.

The service’s managers and provider had developed and carried out audit checks to develop the safety and quality of people’s care. The registered manager and care quality manager were working closely to achieve improvements through the use of these checks. Team handovers took place daily to discuss updates and issues, however this needed to be expanded to involve staff members across the service. We found that development needs had been identified, but corrective actions at times needed to be more effective, as some issues were recurring.

We made a recommendation regarding individual staff feedback and performance management as part of effective quality assurance.

We found and reviewed with the team some aspects of record-keeping across the service that needed to be improved to provide consistently safe, quality care for people.

We made a recommendation regarding the use of regular checks.

Improvements had been made across the key questions we ask. However, due to some concerns we could not improve the rating for safe, effective and well-led, as well as the overall rating for the service. We recognised the efforts the registered manager and team at Broadway Nursing had made to achieve these improvements. The team were also aware there was more work to do. We found the staff we met during the inspection warm, welcoming and engaging.

The team was led by a long-standing registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe living at the service and there were generally enough staff to meet their needs. Staff felt short notice absence at times increased their workload. The registered manager was addressing this. Staff had been recruited using appropriate checks.

Risks for people had been assessed and measures had been put into place to help protect them. The registered manager analysed incidents and accidents to learn lessons from what had happened and help prevent reoccurrence. Staff were knowledgeable about safeguarding procedures and concerns had been investigated appropriately.

External and internal audits had identified that aspects of medicines management needed to improve. The service was working in partnership with their pharmacist and GPs to improve this. People and relatives told us the service was always clean and we found this when we visited.

The service worked in partnership with a variety of health professionals to achieve good outcomes for people. People were supported to eat and drink well. We found some of the recording around people’s weights, nutrition and health needs required review.

The adaptation of the environment needed further development to be more accessible and dementia-friendly. An assessment system helped the service to support people’s rights under the Mental Capacity Act 2005 and act in their best interest. Staff felt well supported in their role.

The majority of staff had worked at the service for a long time. This created a kind, close “family-like” feel that people, relatives and staff told us about. People and relatives were involved in decisions over their care and bedrooms had been personalised. The service had made improvements to protect people’s confidential records more robustly.

Overall, people and relatives told us that staff knew them and their needs well. We found some good examples of person-centred care and planning. We considered with the team how other areas could be developed. The service had identified that the activities on offer needed to be developed. However, we also observed staff looking for ways to engage and stimulate people when activities coordinators were not available. Staff had arranged birthday celebrations for people and involved them in the creation of a service calendar.

People and relatives knew how to make a complaint and we saw complaints had been recorded and investigated by the registered manager. We also saw compliments from relatives and external professionals. This included praise for the good, compassionate care the service provided at the end of people’s lives.

The service produced a monthly newsletter to keep people and relatives up to date and sought stakeholder feedback and involvement through surveys. Information was available to people on prominent notice boards, which also promoted a service that was inclusive of people and staff’s diverse needs. Relevant notifications had been sent to CQC in line with legal requirements.

Broadway Nursing is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Broadway Nursing provides accommodation, personal care and nursing care for up to 43 adults some of whom have complex needs. The service is situated in the Clubmoor area of Liverpool and is close to shops, pubs and other places of local interest. At the time of the inspection there were 42 people living in the home.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; safe, effective, caring, responsive and well-led to at least good.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our last inspection in January 2017, we found that the provider was in breach of regulation 12 because; the environment was not maintained to ensure people's safety. Chemicals were not stored securely, not all fire doors had been adequately maintained and water temperatures were not within safe ranges. On this inspection we found that improvements had not been made to a standard that kept people safe. This meant the provider remained in breach of regulation 12 (Safe care and treatment).

During our last inspection in January 2017, we found that the provider breached regulation 18 because supervisions and appraisals were not completed regularly and not all staff had completed safeguarding vulnerable adults or safe management, storage, recording and administration of medicine training. During this inspection we found improvement to the completion of staff training. However, the supervision matrix provided during the inspection showed that some staff had not received supervision or appraisal as scheduled. This meant that the provider remained in breach of regulation 18 (Staffing).

During the last inspection we found that the provider was in breach of regulation 17 because care files were not always stored securely in order to maintain people’s confidentiality. We also found that care records were lacking in sufficient detail and audit processes had not been effective in identifying concerns and improving practice. As part of this inspection we checked to see if practice had improved.

On our initial tour of the building we were shown into the lounge and saw that two care records had been left unattended on the table and were accessible in the same manner as at the last inspection.

We looked at a total of eight care records. In seven records we found that the care plans held sufficient information to instruct staff and showed evidence that people and their relatives had been involved in the review of person-centred assessments and care plans. However, we also found that care plans for a person who had been admitted five days before our inspection started had not been completed. This meant that care and nursing staff did not have adequate guidance on how to meet this person’s needs.

The registered manager and the care quality manager completed audits on a regular basis. Actions had been identified in relation to a range of subjects. However, some actions had not been completed as scheduled. This meant the provider remained in breach of regulation 17 (Good governance).

We asked people about the food at Broadway Nursing. The majority of people said they enjoyed the food and had a good choice. However, some people commented that the food was not always well-prepared or presented. Improvements to the dining experience had not been made following findings from the last inspection.

Staff were not always recruited in accordance with requirements of the regulations. We looked at four staff files and found that people’s employment histories were not always complete and photographic identification was not on-file. We made a recommendation regarding this.

The environment had been partially adapted to meet the needs of people with mobility difficulties and those living with dementia. However, adaptations were limited to non-slip flooring and basic signage. We made a recommendation about assessing the suitability of the environment to meet people’s needs.

We observed the administration of medicines and checked a range of records. We found that improvements had been made to the management of medicines and that safe systems were in place.

We asked people their views of how the home was managed and feedback was positive. Staff were equally positive about the management of the home and spoke enthusiastically about their job roles. They said that roles and responsibilities were clear and they knew who to speak to if they needed guidance or support.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications. The ratings from the previous inspection were on display in accordance with requirements.

People and their relatives told us that there were not enough activities to keep people occupied and stimulated. On the day of the inspection we did not observe any activities other than a clothes sale which was attended by a small number of people.

We looked at processes in place to gather feedback from people and listen to their views. The relatives we spoke with confirmed they received annual surveys to gather their feedback. We saw evidence of the most recent survey which contained mainly positive responses. It showed a significant improvement over the results of the previous survey.

The nurses that we spoke with had a good understanding of people’s needs in relation to end-of-life care. This included people’s needs in relation to their faith and pain management. Detailed end-of-life care plans were produced with people, their families and healthcare professionals as appropriate.

People living at the home told us staff were kind and caring and treated them with respect. The registered manager and nurses provided care and support throughout the inspection and used the opportunity to observe the quality of care provided by other staff. Our own observations showed that staff knew people well and treated them with kindness.

Staff were clear about their responsibilities to protect people’s rights to privacy and dignity in the provision of care. They explained how personal care was given in the privacy of people’s bedrooms or in locked bathrooms. All the people that we spoke with confirmed that staff treated them with respect when providing personal care.

People told us their cultural and religious needs were respected by the service and were recorded in people’s care records. We were told of examples where people’s requirements in relation to their faith and food were supported by the home. Care records included plans which reflected people’s end of life wishes.

The home was operating in accordance with the principles of the Mental Capacity Act 2005. Applications to deprive people of their liberty were submitted to the local authority only when required, in the best interests of the person and were always supported by a mental capacity assessment.

People at the home were supported by the staff and external health care professionals to maintain their health and wellbeing. The majority of referrals to other health professionals were made in a timely way when people’s needs changed. However, one referral had not been followed-up to ensure that it had been received and acted on.

Staff were deployed in sufficient numbers to keep people safe and meet their needs. Staff understood their responsibilities in relation to adult safeguarding and knew how to report any concerns. Records indicated that safeguarding referrals to the local authority had been made appropriately.

We looked at accident and incident reporting within the home and found that these were reported and recorded appropriately to help ensure people’s safety. We saw evidence that accidents and incidents were analysed to look for patterns and trends.

You can see what action we told the provider to take at the back of the full version of this report.

Broadway Nursing is a nursing and residential care home that provides accommodation, nursing care and support for up to 43 adults some of whom have complex needs. The service is situated in the Clubmoor area of Liverpool and was close to shops, pubs and other places of local interest. At the time of the inspection there were 38 people living in the home.

When we last inspected Broadway Nursing in July 2014, the provider was found to be compliant with regulations and the service was rated good in all domains and overall.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found that risk in the environment was not always minimised. For instance items that could pose risks to vulnerable people, such as razors, were not always stored securely. The door to one person’s room did not close as the automatic closure device was broken. We discussed this with the registered manager and this was repaired by the second day of the inspection. Some radiators around the home were very hot to the touch and could pose a burns risk. Both internal and external checks were completed regularly to help ensure the building and equipment was safe, however water temperatures were not all in safe ranges and were awaiting repair.

Medicines were not always managed safely in the home. Temperatures of the storage room and medicine fridge were meant to be recorded daily, but these checks had not been recorded daily. There were no plans in place to ensure people received medicines prescribed as needed (PRN) when they needed them. Prescribed thickening agents were not signed as administered and recording of allergies was not consistent.

We received mixed feedback regarding staffing levels from relatives and people living in the home, though staff told us there were sufficient numbers of staff to meet people’s needs. Our observations showed us that there were sufficient numbers of staff on duty, but they were not always deployed most effectively.

Staff told us that they received regular training, though not all staff had completed safeguarding training and two staff had not undertaken medicine training or had their competency assessed.

Staff told us that they felt well supported and that they could approach the registered manager if they had any concerns. There did not appear to be programme for staff supervision as they had only been held in January 2016 and appraisals in October 2015. Staff that were new to care had completed an induction which was in line with the principles of the Care Certificate.

Staff we spoke with told us they always asked for people’s consent before providing care. When people were unable to provide consent, mental capacity assessments were completed. Though most of these were completed appropriately, some of the assessments did not follow the principles of the Mental Capacity Act 2005.

Our observations showed that the quality of interactions between staff and people living in the home varied. We observed some very warm and positive interactions during the inspection. However, we also observed interactions that were not as positive.

Care files were not always stored securely in order to maintain people’s confidentiality. This meant that people could access confidential information that did not need to.

We found that although audits were completed to assess the quality of the service, actions were not always taken to address issues they identified. Issues identified through an external service risk assessment had not all been addressed by the provider. The provider was aware of issues within the home through regular visits and an internal quality assurance monitoring schedule.

Care plans that had been reviewed using the newly introduced care plan system were detailed and person centred, however those that had not yet been reviewed using the new approach lacked detail and personalised information. Not all care plans reflected accurate information regarding people’s needs and preferences. This meant that not all staff had accurate information regarding people’s needs.

Planned care was not always evidenced as provided. For example, one person’s care file reflected they required their blood pressure to be monitored monthly due to a health condition, but this had not been completed. We also found that risk assessments regarding people’s care needs were not always completed accurately to identify the correct level of risk.

People we spoke with told us they felt safe living in Broadway Nursing. Staff had a good understanding of safeguarding processes and staff were recruited following relevant checks to ensure they were suitable to work with vulnerable people.

DoLS applications had been made appropriately for people who required one.

People at the home were supported by the staff and external health care professionals to maintain their health and wellbeing. People told us they were supported to access medical services when required.

Feedback we received regarding meals was positive. Staff were knowledgeable about people’s dietary needs and preferences. People had a choice of main meal and alternatives were always available. People could have snacks when they wanted them and they had plenty to drink

People living at the home told us staff were kind and caring and treated them with respect. We observed people’s dignity and privacy being respected by staff in a number of ways during the inspection, such as staff knocking on people’s door before entering their rooms. People told us staff supported them to maintain or improve their independence when supporting them.

We found on discussion, that staff knew the people they were caring for well, including their needs and preferences. Care plans included information regarding people’s preferences.

Care files included detailed information regarding any medical conditions the person had, such as signs and symptoms and a definition of the condition. This helped to ensure that staff had an awareness of people’s individual medical needs and how these may impact on the person.

Most people we spoke with did not recall being involved in their care plan but thought that their family members were involved.

People told us their cultural and religious needs were met by the service. One person told us about a priest who visited the home each week and provided individual Holy Communion.

We observed relatives visiting throughout both days of the inspection. The registered manager told us there were no restrictions in visiting, encouraging relationships to be maintained.

For people who had no family or friends to represent them, contact details for a local advocacy service were available within the home for people to access.

People had access to call bells in their rooms to enable them to call for staff support when required.

There was an activities coordinator employed by the service and people told us they were very enthusiastic and provided a number of activities. There was a planned schedule of activities advertised and we observed bingo and karaoke take place during the inspection.

People living in the home that we spoke with were not aware of any meetings or questionnaires to gather their feedback. Relatives we spoke with confirmed they received annual surveys and we found that these were last issued to people in 2016. There was however, no evidence to show that this feedback had been acted upon. Most people we spoke with were not aware of resident or relative meetings and there were no records to show when these were last held.

People had access to a complaints procedure and this was displayed within the home and available within the service user guide. People we spoke with told us they had not had reason to make a complaint, but knew how to raise an issue should they have to.

Staff told us they enjoyed working at the home and one staff member described Broadway Nursing as a happy home. Staff told us that they worked well together as a team to meet the responsibilities of their roles and the values of the service.

The provider had policies and procedures in place to guide and inform staff on all aspects of their role. Staff were aware of the home’s whistle blowing policy and told us they would not hesitate to raise any issue they had.

Staff we spoke with told us they had regular team meetings and felt able to share their views during these meetings and that they were listened to.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications. This meant that CQC were able to monitor information and risks regarding Broadway Nursing.

You can see what action we told the provider to take at the back of the full version of this report.

'They look after you well.'

'The staff are kind and caring.'

'I call the staff angels.'

The people who lived at Broadway Nursing were cared for by staff who were appropriately recruited, trained and experienced at supporting them. However we found that appropriate arrangements were not in place for the management of the medicines and the provider had not always made appropriate safeguarding referrals to the relevant agencies.