Broadway Lodge Residential Home

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.

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

Quality Monitoring systems in place, were not always effective and failed to identify some of the shortfalls found at inspection. Records relating to the management of the service lacked detail and did not effectively monitor the service. Quality assurance records in place did not always contain accurate information or identify actions to make required improvements.

People's needs and choices were assessed. However, People’s care plans and risk assessments lacked some important details. Records did not always accurately reflect people's care needs to ensure people’s health, safety and welfare was appropriately managed.

People told us they felt safe. Staff understood their responsibilities to report any safeguarding concerns. People and relatives spoke positively about the kind nature of the staff team. Staff knew people well and treated them with kindness and compassion in line with their preferences.

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 provider worked in partnership with stakeholders, people and relatives to obtain feedback about the service.

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 18 March 2019)

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.

Why we inspected

This inspection was prompted by a review of the information we held about this service. This inspection was also carried out to follow up on action we told the provider to take at the last inspection. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Broadway Lodge Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and management oversight of the service at this inspection.

Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the home was clean and staff and people who used the service participated in testing for COVID-19. Staff had made some changes and improvements to infection prevention and control practices, following recommendations from infection control specialists. However, further improvements were still required in a number of areas to ensure all policies and practice were in line with government guidance and best practice.

We identified a breach of legal requirements in relation to infection prevention and control.

Full information about the Care Quality Commission’s (CQC) regulatory response to more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Broadway Lodge Residential Home is a care home providing personal care for up to 18 older people. At the time of our inspection 16 people lived at the service.

People’s experience of using this service

Risks to people were not always identified and managed. Lessons learnt following incidents were not always considered and acted on. Records were not up to date and checks in place to monitor the quality of care being provided had not identified or addressed the concerns found. The environment was not in line with best practice and there was a lack of understanding and acknowledgement of best practice guidance.

The registered manager was supported by a management team. Recruitment processes were in place but not always robust. We have made a recommendation regarding consistency in recruitment.

The service was family run and homely. People, their relatives and staff all felt part of one big family. Staff were extremely caring and attentive to people’s needs. People were supported to access additional services including the GP on a regular basis and when needed.

People were supported with their communication needs and staff demonstrated effective skills in communication. Staff had received training and support to enable them to carry out their role. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People were supported with activities and interests to suit them. Staff knew people’s likes and dislikes well. Staff told us the management team were approachable. The provider had systems in place to safeguard people from abuse.

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

The last rating for this service was good (published 9 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to record keeping, the management of risk and cleanliness of the service at this inspection.Please see the action we have told the provider to take at the end of this report.

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 Lodge Residential Home is a care home providing accommodation and personal care for up to eighteen older people. At the time of our inspection there were 13 people using the service. The home is located in Fulford, on the outskirts of York. The home is owned by Mr & Mrs H Mohamudbaccus. Mrs Mohamudbaccus is also the registered manager of the service. 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. The provider had policies and procedures in place to guide staff in safeguarding vulnerable adults from abuse, and staff we spoke with understood the different types of abuse that could occur and were able to explain what they would do if they had any concerns.

Support provided with medicines was recorded on medication administration records. Staff responsible for supporting people with medicines had received training and the registered provider was in the process of implementing a new medicines management policy.

The registered provider had a safe system for the recruitment of staff and was taking appropriate steps to ensure the suitability of workers. There were mixed views about whether there were sufficient staff available, especially at night. We found there were sufficient staff available to keep people safe and meet their needs and the registered provider agreed to keep staffing levels under review.

Risk assessments were in place to minimise the risk of harm to people, but not all of these had been written and reviewed in a timely manner.

Staff were able to demonstrate an understanding of the importance of gaining consent before providing care to someone and we found the service to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

People were supported to maintain good health and access healthcare services. We saw evidence in care files that people had accessed a range of healthcare support. People were supported with their nutritional needs.

Staff completed training and received on-going supervision to help them carry out their roles effectively. Staff meetings were also held regularly.

People told us that staff were caring and treated them with dignity and respect. We saw that interactions between people and staff were warm and friendly and staff knew people’s needs and preferences. Relatives told us staff kept them informed about any changes or concerns.

There was a quality assurance system in place, which included audits and satisfaction surveys, but we found the registered provider had not been proactive in driving improvement through the effective use of quality auditing systems. The registered manager had not met all legal requirements in relation to notifying the Commission of DoLS authorisations in place and displaying their most recent performance rating.

Feedback about the leadership of the service and the registered manager was positive and people were satisfied with the care they received.

We spoke in detail with five people who used the service and with members of staff including the two providers, four care staff and the chef. We spoke with four visitors to the service and with one social care professional. We also reviewed documentation including three care plans, service and maintenance records and kitchen records.

We found that effective management systems were in place to safeguard and promote people's safety and welfare. Good professional relationships appeared to exist between people who lived at Broadway Lodge Residential Home and the staff team.

Care needs were discussed with people and/or their relatives and before people received care their consent was asked for. One person said, 'Staff are lovely and always ask me about what I want to do. Another person said, 'I appreciate all the care they give to me.'

People were provided with a choice of suitable and nutritious food and drink. Overall, we found that the service was clean and well maintained and one relative told us the service was always 'Spotless.'

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We saw evidence that people were asked before any care was carried out and this was done in an appropriate manner. The service did not have signed consent forms but people had signed parts of their care plan.

We looked at most areas of the premises and found them to be clean and hygienic. We spoke with staff who showed a good understanding of infection control and we saw evidence that most staff had completed the relevant training. There were policies and procedures in place that were followed appropriately.

The management had carried out the necessary checks before employing staff and the recruitment and selection procedure was robust. We looked at the amount of staff that were working in the home and found this to be appropriate. Some staff did feel that they were sometimes very busy but people who lived in the service felt well looked after and able to get support when they needed it.

We saw that the storage and retention of paperwork was appropriate. All the documentation we looked at was detailed, accurate and up to date.