Broadway Lodge Residential Home

Updated 5 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was completed by two inspectors.

Service and service type

Broadway Lodge Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. [Care home name] is a care home [with/without] nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post. The registered manager was working alongside a new manager who was looking to take on the registered manager position.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people about their experience of the care provided. We spoke with seven staff including the registered manager, manager, and care workers. We reviewed a range of records. This included two people's care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 5 December 2023

About the service

Broadway Lodge Residential Home is a residential care home providing personal and nursing care to 17 people aged 65 and over at the time of the inspection. The care home can accommodate 18 people in one adapted building

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

The providers' governance systems had not identified the shortfalls found at this inspection. There were still areas of the service that were not always appropriately monitored. We continued to find recording issues within recruitment files and accident and incident records.

There was no system in place to support the provider to assess/calculate nighttime staffing levels to meet people’s needs.

Accidents and incident audits did not fully review all accidents and incidents at the service. Incident forms completed did not always contain the details of actions taken or actions needed to prevent a re-occurrence or to mitigate risk.

Staff were clear about the action to take in the event of a fire. However, records relating to fire safety and staff attending fire drills showed only 6 staff had attended a drill in the past year.

People received their support from regular staff whom they knew well. Staff promoted person centred care, upheld privacy and dignity and treated people with respect. Medicines were managed safely and the service was clean, friendly and welcoming.

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.

The manager actively sought information, guidance and advice from stakeholders and agencies to support the service to make improvements.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 12 October 2022). 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 the provider remained in breach of regulations.

The last rating for this service was requires improvement (published 12 October 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We undertook this focused inspection to check whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have identified breaches in relation to the governance of the service at this inspection. Following this inspection, we wrote to the provider to request an action plan and to gain further assurances for people's safety.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. We will continue to monitor information we receive about the service, which will help inform when we next inspect.