Background to this inspection
Updated
25 June 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
The inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Broadland House 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 who was in the process of registering with the Care Quality Commission. Once the manager is registered this will mean 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.
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 one person who used the service and 10 relatives about their experience of the care provided. We spoke with eight members of staff including the nominated individual (the nominated individual is responsible for supervising the management of service on behalf of the provider), manager, cook and recruitment assistant. In addition, we spoke with two healthcare professionals, who regularly visited the service.
We reviewed a range of records. This included seven 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 maintenance records were reviewed.
After the inspection
We continued to seek clarification from the manager to validate evidence found. We looked at policy and procedures, training data and quality assurance records.
Updated
25 June 2021
About the service
Broadland House is a residential care home providing personal care to 20 people aged 65 and over, some of whome were living with dementia, at the time of the inspection. The service can support up to 20 people.
Broadland House accommodates 20 people in one adapted building.
People’s experience of using this service and what we found
Actions to manage risks had not always been taken. The inspection identified several environmental risks which placed people at risk of harm. Actions had not been taken to fully assess people at risk of malnutrition. Quality Assurance systems had not been effective at identifying or addressing and improving these areas in a timely manner.
The service was open and inclusive which empowered staff in caring for the people who lived at the service. There had been a change of manager and the structure of how the service was being managed was being reviewed. However, during this the time the feedback from staff and relatives of people who lived in the service was positive with the managers being approachable and proactive in supporting people and staff. The staff had felt valued during recent times of COVID-19, receiving gifts and support for their wellbeing.
People’s records were regularly reviewed, were person centred and easy to understand.
Relatives spoke positively about the service regarding how they had been kept in contact with and updated during COVID-19. They were pleased with the care received and felt they could approach staff with queries and concerns and be listened to. Professionals involved with the service said staff were always helpful, notified them of any changes and were open to consider new strategies and ways to help support the people who lived in the service.
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 26 October 2019).
Why we inspected
We received concerns in relation to the management of medicines, environment and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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.
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 assessing risk, safety monitoring and management and continuous learning and improving care sections of this full report.
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 Broadland House on our website at www.cqc.org.uk.
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 monitor the service.
We have identified breaches in relation to safe care and governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.