Broadoak Grange

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, and safeguarding.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had not embedded a positive learning culture to support people to manage risks to their health, safety and wellbeing. Systems for recording, reviewing and learning from accidents and incidents were not robust.

Incident records were not always fully completed or followed up. Follow-up actions, monitoring and investigations were sometimes missing, and some incidents had been signed off before actions had been completed. Reporting to external agencies was not always consistent. Care plans and risk assessments were not routinely reviewed following incidents, and known risks were not always updated to reflect learning. Where patterns and themes were identified, there was limited evidence of actions taken to reduce the risk of recurrence. This meant the provider could not demonstrate lessons were consistently learned from incidents to improve people's safety and outcomes.

Although an audit identified all recorded skin tears during 1 month occurred between 7:00am and 12:00pm, there was no evidence of analysis into the potential causes or of actions taken to reduce the risk of recurrence. In addition, the monthly accidents and incidents audit in August failed to identify 2 accidents that had occurred during the review period. The audit did not contain analysis of themes or trends and had not been signed to confirm who had completed it. This meant the provider could not demonstrate incidents were being effectively monitored, reviewed and used to drive improvements in people's safety and outcomes.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider had processes in place to assess people's needs before they moved into the service; however, systems for sharing information and supporting safe transitions were not always effective. Staff told us they were not consistently informed in advance about new admissions or provided with sufficient information about people's care and support needs. One staff member said, “We just get told a new resident is coming in and whether they are a single or double assistance for support.” Another told us, “With new residents, unless you go and pick up their care plan, we have no clue about them.” This meant staff did not always have timely access to the information required to provide safe, person-centred care when people first moved into the service.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Although people and their relatives told us they felt safe, 1 person said, “I am a lot safer than I was at home, I was falling at home, and nobody to help me.” However, we identified concerns regarding the provider's oversight of Deprivation of Liberty Safeguards (DoLS) authorisations and conditions.

The provider could not demonstrate effective monitoring of DoLS applications or compliance with conditions attached to authorisations. Records showed 1 person's DoLS application had been submitted a significant time ago, but there was no evidence the provider had followed up its progress with the supervisory body.

We also found conditions relating to the review of medicines were not consistently met. One person's DoLS authorisation required regular reviews of medicines; however, no evidence of these reviews was available within care records. For another person, a DoLS condition required an immediate GP review of medicines, yet records indicated the review was not arranged when required and the provider was unable to explain the delay or demonstrate how risks had been managed in the interim.

There was a lack of effective oversight and monitoring of safeguarding. Despite repeated requests during the inspection, the registered manager stated there was no safeguarding folder or central record of safeguarding concerns within the service. As a result, we were required to contact the local authority directly to establish the number and nature of safeguarding concerns raised about people living at the home.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People did not always have detailed guidance in place to support staff to respond safely and consistently to known risks. For example, 1 person displayed periods of distress, including incidents of aggression towards staff. Although these behaviours were known to the provider, behaviour support planning lacked sufficient information regarding triggers, preventative strategies and the actions staff should take to minimise distress and keep the person and others safe. Following concerns raised during the inspection, the care plan was updated; however, it remained insufficiently detailed to provide staff with clear guidance. This placed the person at risk of receiving inconsistent or inappropriate support and increased the risk of avoidable harm to both the person and staff.

The provider also failed to adequately assess and manage risks associated with epilepsy. Despite a long-standing diagnosis and prescribed anticonvulsant medication, there was no epilepsy care plan in place to guide staff on seizure presentation, known triggers, management of seizures or when to seek emergency assistance. Staff had not received epilepsy-specific training to support them in responding appropriately. Although an epilepsy care plan was introduced after concerns were identified during the inspection, the absence of appropriate care planning and staff training had placed the person at risk of avoidable harm, injury and delayed treatment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider did not always ensure effective fire safety arrangements were in place. Fire evacuation information was unclear and inconsistent, with discrepancies between signage, fire maps, training records and emergency documentation. Staff told us they were not confident with evacuation zones and were unfamiliar with full evacuation procedures.

Systems to support safe evacuation were not robust. Emergency grab sheets and contact records contained incomplete or outdated information, and fire drill records lacked sufficient detail to demonstrate learning and preparedness. Although people had Personal Emergency Evacuation Plans (PEEPs), these were not person-centred and often lacked important information, such as evacuation routes, how people with mobility needs would be evacuated from upper floors, visual impairments or distressed behaviours, and consideration of restrictions on people's liberty. The provider could not demonstrate staff had the information required to evacuate people safely in an emergency. However, regular checks were carried out, including scheduled servicing and safety inspections such as electrical compliance testing and fire risk assessments.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff did not always receive the training and competency assessments required for the tasks related to people’s health they were expected to undertake. Some staff had also not completed learning disability training in line with the requirements of the Health and Care Act 2022 which is a legal requirement for CQC-registered providers. This placed people at risk of receiving support from staff who may not have had the necessary knowledge, skills and experience to meet all their needs safely and consistently.

People and staff raised concerns about staffing levels, particularly at night. One person told us, “At nights there is sometimes only 2, they can struggle if it's busy, 3 can cope better.” They explained this could result in staff taking longer to meet people's needs. Staff echoed these concerns, with 1 member of staff stating, “Three staff should be on at night but there is a lot of nights when there are 2 staff on and it's unsafe.” Another staff member told us, “Training needs improving, a lot of the carers seem to not know what to do.”

Care staff were also expected to undertake additional duties, including cleaning, laundry and serving meals during the afternoon. This reduced the time available to support people with their personal care needs and increased the risk that people may not receive timely care and support. While we observed interactions between staff and people were caring, they were often task focused rather than spending meaningful time with people. Staff confirmed this, one comment included, “Sometimes there’s no one on the floor as we are all caring for people.” Another told us, “We [care staff] go round cleaning the lounges, hoovering and things like that, doing laundry through the night, we pop people to bed. Sometimes people are restless, so we bring them into the lounge to keep an eye on them, we will give them a blanket, snacks, then we keep on doing checks throughout the night every couple of hours, repositioning those who need it.”

Recruitment processes were not always robust, with gaps in employment history not consistently explored to help ensure staff were suitable for their roles. However, the provider had undertaken Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified concerns with infection prevention and control practices, including unsecured clinical waste that was accessible to the public, and inadequately managed sharps containers within the medicines room. Equipment used to support people's care, such as wheelchairs, pressure-relieving equipment and commodes, was not always clean or maintained in a suitable condition.

Several bedrooms and communal facilities showed evidence of poor cleanliness and maintenance, including stained or malodorous mattresses and bedding, soiled toileting equipment, rusted commodes, limescale build-up, unpleasant odours, and dirty flooring. We also found damaged equipment and furnishings, including split crash mat covers, which could not be effectively cleaned. These issues placed people at increased risk of exposure to infection and did not demonstrate effective infection prevention and control practices.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Transdermal patch (medicines absorbed through the skin) application records were not completed consistently over an extended period. Records repeatedly failed to identify the site of application and there was no evidence that daily checks had been completed to confirm patches remained in place. This increased the risk of patches being applied to the same site repeatedly, medicines not being absorbed effectively, or patches becoming detached without being identified.

Medicines administration records for prescribed laxatives were not always completed accurately. A handwritten transcription had not been double signed to verify accuracy and the prescribed variable dose lacked guidance for staff on when each dose should be administered. On multiple occasions records did not state whether 1 or 2 sachets of the medicine had been given. This meant staff could not demonstrate the prescribed dose had been administered and increased the risk of under or over-treatment, avoidable discomfort and medicines errors going undetected.

The provider failed to ensure staff had sufficient guidance for the administration of 'as required' medicines and emergency treatment for people living with diabetes. Records identified PRN insulin and glucose treatments were prescribed; however, appropriate protocols were not in place and care records lacked clear instructions for staff. In addition, some treatments referenced within care plans were not prescribed on medicines administration records. The absence of clear protocols, inconsistent records and lack of guidance regarding emergency diabetic treatment placed people at risk of delayed or inappropriate intervention.

We also observed medicines being left unattended with a person who was unable to reliably communicate whether they had taken them. Staff told us this was routine practice; however, there was no risk assessment to support this approach. The provider had failed to assess and mitigate these risks to ensure medicines were administered safely.