We carried out a review of the data available to us about Broom Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Broom Lodge, you can give feedback on this service.
Broom Lodge is a residential care home providing personal care for up to 6 people with learning disabilities or autistic people. At the time of our inspection 5 people were living at the service.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support
People were involved in discussions about their support and given information in a way they understood. Staff supported people to take part in activities and pursue their interests in their local area. Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcome.
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.
Right Care
People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. The service had enough appropriately skilled staff to meet people’s needs and keep them safe. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
Right Culture
People led inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff. The provider had developed the service to support and improve the lives of people living or staying at the service. The values of the service underpinned the support people received. People were empowered to lead fulfilling lives and make choices about how to spend their lives.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published February 2022) and there were breaches of regulation. 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.
At our last inspection we recommended that the provider review their systems and processes for embedding the principles of ‘right support, right care, right culture’. At this inspection we found the principles of ‘right support, right care, right culture’ had been embedded within the service.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last 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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
About the service
Broom Lodge is a care home which can provide personal care for up to six people with learning disabilities or autistic people. At the time of this inspection there were four people living at the service.
People’s experience of using this service and what we found
Staff aimed to support people to have maximum choice and control of their lives. Staff were not always able to support people in the least restrictive way possible. Mental capacity assessments were not always decision specific and lacked detail about how a person’s capacity had been assessed.
The provider has put a quality assurance system in place. The area manager and registered manager completed regular audits of the service and when they identified issues put action plans in place. We found the governance arrangements did not always identify gaps in practice.
Not all staff working at the service had completed or updated their mandatory training. People’s care and support plans sometimes contained conflicting information and following feedback the registered manager made improvements to their record keeping regarding visits from healthcare professionals.
Information about risks to people sometimes lacked detail and people’s care records were not routinely provided in an accessible format.
The registered manager used a dependency tool to calculate the number of staff needed and there were enough staff on duty to support people. Staff supported people to pick their meals and made sure they had enough to eat. Staff provided opportunities for people to engage in meaningful activity and access the community. Medication storage, handling and administration were generally effective.
We observed staff deliver care and support in a kind and compassionate manner. Staff were dedicated and committed to providing an effective service. Relatives found staff were fantastic and created a warm and friendly environment.
Staff adhered to COVID-19 guidance on working in a care setting.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 1 April 2021 and this is the first inspection.
Why we inspected
In September 2021 we completed a direct monitoring activity, which involved gathering feedback from staff, relatives and people who use the service as well as looking at a wide range of documents. This identified some areas of practice, which were potentially of concern and this triggered the inspection. These were particularly around supporting people to manage their emotions and consistency of care.
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 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 identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, and good governance.
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 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.