Broadoak Grange

We found the following examples of good practice.

Safe staffing levels were maintained at the service. All staff had completed training in relation to infection prevention and control (IPC) and correct use of personal protective equipment (PPE), including how to put it on and remove it safely. Regular refresher training sessions were undertaken by the manager who also completed regular competency checks.

Activities were encouraged in a socially distanced manner to support people to engage in meaningful activities and to minimise impact on their wellbeing. Activities were repeated throughout the week to allow equal access for people.

Cleaning schedules were in place and frequency of cleaning had been increased throughout the COVID-19 pandemic. During the day high touch areas were cleaned every two hours and communal areas were cleaned every four hours with appropriate cleaning products.

Policies, procedures and risk assessments in relation to COVID-19 were up to date and reviewed regularly.

Broadoak Grange is a residential care home providing personal care for up to 33 people. At the time of the inspection 29 people were using the service. Accommodation is provided over the ground and first floor with a mixture of ensuite rooms and communal facilities.

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

The majority of people we spoke with commended the home. People felt safe and well cared for. People's preferences were respected, and staff were sensitive and attentive to people's needs. Staff were seen to be kind, caring and friendly and it was clear staff knew people and their relatives well.

There were sufficient numbers of staff employed to ensure people's needs were met. We saw staff had time to engage people in conversation.

Recruitment practices were safe, and staff received the training they required for their role.

Risks to people's health, safety and well-being were assessed and care plans were in place to ensure risks were mitigated as much as possible.

Staff were aware of their responsibilities to safeguard people and the home had robust procedures in place.

People's care plans contained personalised information detailing how they wanted their care to be delivered.

Staff were keen to ensure people's rights were respected including those related to disability and dietary requirements.

People received their medicines safely and as prescribed. Medicine management practices were safe.

People were supported to eat and drink enough. Staff supported people to live healthier lives and access healthcare services when required.

The service was provided in a homely and clean environment.

Consideration was given to providing a variety of leisure and social activities for people to enjoy.

Quality assurance systems were in place to assess, monitor and improve the quality and safety of the service provided.

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.

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 (report published 02 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.

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.

Broadoak Grange is a care home without nursing and provides care and support for up to 33 older people, people with dementia and physical disability. At the time of the inspection there were 28 people using the service.

There was a registered manager in post. It is a requirement that the service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Staff understood their responsibilities about protecting people from abuse and avoidable harm. Risk was assessed and management plans were put in place. People's freedom to make informed decisions and take risks was supported.

There were sufficient numbers of staff to meet people's needs. Pre employment checks were carried out so that so far as possible only staff with suitable character and skills were employed.

People's medicines were managed so that they received the right medicine and at the right time.

Staff had received training and knew how to meet people's individual needs. Consent was sought in line with legislation and guidance. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way.

People were supported to eat and drink a varied and nutritious diet. They had access to the healthcare services they required.

Staff were caring, compassionate and treated people with respect. People had their privacy and dignity respected.

Care and support was delivered in the ways that people preferred. People felt comfortable making a complaint and confident they would be listened to.

The culture of the service was open and inclusive. There was a clear organisational structure and staff understood their responsibilities. The quality of the service was monitored and changes were made to continually improve.

Broadoak Grange is a care home for older people and is registered to accommodate up to 33 people requiring care because of old age, physical disability or dementia. At the time of our visit there were 31 people using the service.

There should be a registered manager at 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. The manager had submitted her application to become the registered manager of the service and it was being processed at the time of our inspection.

People felt safe at the service. People felt able to talk to staff with any concerns. People received their medicines as prescribed. There was not appropriate information available relating to a person's covert medicine. People's privacy and dignity was respected.

There were sufficient staff on duty. Staff received training to enable them to meet people’s needs. Staff had a good understanding of how to the various types of abuse and knew how to report issues internally and externally.

Risks relating to people’s care had been assessed. Where a risk had been identified action had been taken to reduce the associated risk. Risks relating to the environment had not always been identified and assessed.

Where a change to people’s health had been identified referrals to health professionals had been made. There was a risk that a person was not receiving the right professional support for their behaviours.

The service was working within the principles of the Mental Capacity Act 2005 (MCA). Where there was a reasonable doubt that a person lacked capacity to make decisions the service had a mental capacity care plan in place. However, the information relating to the people's mental capacity was not decision specific and therefore did not fully meet the requirements of the MCA legislation. The service had taken appropriate steps where they had identified that people were being deprived of their liberty in any way and they had made referrals to the local authority as is required.

People told us that the staff were kind and caring. Staff interactions with people were task focused and there were only limited times when staff engaged in general conversation with people.

People's needs were assessed and care plans had been put in place. Care plans contained limited information about people’s likes, dislikes and preferences. People did not always receive personalised care that was responsive to their needs.

Staff and the manager shared a vision of the service. Staff were clear about the expectations upon them within their roles. Staff felt valued and listened to and explained how they all worked together as a team.

Monitoring systems that were in place were not always effective at assessing, monitoring and improving the service provision.

We looked at infection control polices and procedures. The environment was clean and fresh. Staff followed polices and procedures designed to reduce the risk of cross infection. Staff interacted with people who used the service in a positive and respectful way. Staff demonstrated a good understanding of people's individual needs.

The provider had made some improvements since our inspection of 13 September 2012. However, the planning and delivery of care did not meet the individual needs of some people. Some people felt they were not asked for feedback about their experience of the care they received. The provider had begun asking for feedback from the relatives of people who used the service. However there were no formal mechanisms for seeking the views of people who used the service.