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Archived: Broad Acres Inadequate

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Inadequate

Updated 23 June 2017

This inspection took place on 3 and 4 April 2017 and was unannounced. At the last inspection on 2 February 2016, we asked the provider to take action to make improvements to the signage and decoration in the service, record keeping and the assessing and how they assessed and monitored the quality of the service. We received an action plan from the provider stating they would meet the relevant legal requirements by 31 May 2016. At this inspection we found that they were still in breach of some regulations. At this inspection we found that although some minor improvements had been made the service still needed to improve further and in some areas had deteriorated.

The service provided nursing care and support for up to 48 people some of whom have mental health needs and others who may be living with dementia. On the days of our inspection there were 34 people living in the service.

The service had a registered manager who was also the provider and clinical lead. 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.

The decoration within the service did not always support the needs of people living with dementia and in some instances was not safe. Quality assurance processes had not identified deficiencies in people’s care plans or shortfalls in the quality of the service provided.

The service did not keep up to date with national safety alerts issued by government. A serious incident had occurred, the circumstances of which had been addressed by an alert. In another case there was no evidence to confirm the service was following safe mouth care practice when an alert had been issued regarding this. People were being placed at an ongoing risk.

Staff did not receive the necessary competency checks. Nurses who had carried out training had not had their competency checked. The registered manager who was also the clinical lead was not aware of their responsibilities in this regard. Therefore people were placed at potential risk of receiving unsafe care and treatment from nurses. Safeguarding training was inadequate to meet the needs of staff as it consisted of a handout and a questions and answers sheet. The service had not introduced the Care Certificate for care staff and therefore the quality of care offered was not as it should be.

An incident which was a safeguarding concern and which was a disciplinary matter had not been recognised as such, reported to the correct authorities or investigated thoroughly. People were not effectively protected from possible harm.

People did not always have their choices and preferences met in how they lived their daily lives. These were not recorded in their care plan and staff did not demonstrate an understanding of the Mental Capacity Act when providing care and support.

Whilst some care staff were observed to provide care and support with kindness and compassion others did not. The approach to care was not consistent and there was no routine monitoring of staff practice to address this. We saw a reliance on staff who were intuitively good carers but no actions in place to support and improve others practice.

Nursing care and clinical governance was poor. The management of pressure ulcers and catheters did not reach required standards. Pressure relieving equipment was not set to the appropriate levels. People were placed at ongoing risk of developing sore skin and not receiving effective treatment for the pressure ulcers they had sustained.

People were not supported with their social needs. The only organised activities observed during the two days of our inspection was a game of skittles.

The leadership of the service was poor. The service quality assurance processes were not used to drive improvement

Inspection areas

Safe

Inadequate

Updated 23 June 2017

The service was not safe.

The service did not follow national safety alerts.

The decoration and furnishing of the building was not managed to keep people safe.

Medicines were not stored and managed safely.

The service did not follow clear disciplinary procedures to ensure staff provided safe care and treatment.

Effective

Inadequate

Updated 23 June 2017

The service was not effective.

Nursing and care staff did not receive appropriate competency checks to provide care based on best practice.

The design, adaption and decoration of the service did not always meet people’s needs.

People were not supported to enjoy their meal and not everybody enjoyed the food.

Caring

Requires improvement

Updated 23 June 2017

The service was not consistently caring.

Staff did not always demonstrate caring compassionate behaviour.

People did not always have their support provided as they preferred.

The display of personal information within the service did not respect people’s dignity

Responsive

Inadequate

Updated 23 June 2017

The service was not responsive.

Care plans did not adequately guide staff on the care and support to be provided and action to be taken.

Where equipment was used to support people’s needs this was not used effectively.

Relevant activities were not provided and people who remained in their bed rooms were in danger of becoming socially isolated.

Well-led

Inadequate

Updated 23 June 2017

The service was not well-led.

Quality assurance audits did not identify shortfalls in the quality of the service.

The service did not keep always up to date with clinical governance best practice.

Improvements identified as being required at our previous inspection had not been sustained.