Broadoaks

Updated 7 October 2021

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 Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by an inspector, and an inspection manager.

Service and service type

Broadoaks is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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 all of this information to plan our inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with two people who used the service about their experience of the care provided. We spoke with five members of staff including the provider, registered manager, care workers, and activities co-ordinator. We used observations to gather evidence of people’s experience of care.

We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at two 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.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 7 October 2021

About the service

Broadoaks is a residential care home providing personal care for up to 39 older people and people living with dementia in one adapted building. The building was split across two floors, each of which has separate adapted facilities. One of the floors specialises in providing care to people living with dementia. There were 16 people receiving a service at the time of our inspection.

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

The provider did not have robust safety and quality monitoring processes in place. People's care records were not always up to date or completed appropriately, and the provider's management checks had not identified these gaps in recording.

Staffing levels were not assessed against a dependency tool to ensure that adequate levels of staff were deployed appropriately. Concerns were raised on quality visits conducted by the local authority. People were being left for periods of time in unstaffed areas of the service. The provider has since increased staffing levels to ensure all areas of the service are staffed at all times.

People received their medicines as prescribed and staff had clear information about how people liked to be supported with their medicines. Staff were knowledgeable about people's health needs and the provider had sought support from other health professionals as appropriate to support people's needs.

Staff wore appropriate personal protective equipment (PPE) and told us they knew how to minimise people's risk of infection through safe infection prevention and control processes.

Staff were safely recruited to the service, and were provided with relevant training for the roles they undertook. All staff training was up to date at the time of inspection.

The provider was , working with the local authorities to address concerns they had found.

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 Good (published 04 December 2018)

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels and risks to people. A decision was made for us to inspect and examine those risks.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report.

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

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to governance and staffing levels 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.