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Broadway Lodge Residential Home Requires improvement

Reports


Inspection carried out on 8 February 2021

During an inspection looking at part of the service

Broadway Lodge is a residential care home providing personal care to up to 18 older people.

We found the home was clean and staff and people who used the service participated in testing for COVID-19. Staff had made some changes and improvements to infection prevention and control practices, following recommendations from infection control specialists. However, further improvements were still required in a number of areas to ensure all policies and practice were in line with government guidance and best practice.

We identified a breach of legal requirements in relation to infection prevention and control.

Full information about the Care Quality Commission’s (CQC) regulatory response to more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Inspection carried out on 17 December 2019

During a routine inspection

About the service

Broadway Lodge Residential Home is a care home providing personal care for up to 18 older people. At the time of our inspection 16 people lived at the service.

People’s experience of using this service

Risks to people were not always identified and managed. Lessons learnt following incidents were not always considered and acted on. Records were not up to date and checks in place to monitor the quality of care being provided had not identified or addressed the concerns found. The environment was not in line with best practice and there was a lack of understanding and acknowledgement of best practice guidance.

The registered manager was supported by a management team. Recruitment processes were in place but not always robust. We have made a recommendation regarding consistency in recruitment.

The service was family run and homely. People, their relatives and staff all felt part of one big family. Staff were extremely caring and attentive to people’s needs. People were supported to access additional services including the GP on a regular basis and when needed.

People were supported with their communication needs and staff demonstrated effective skills in communication. Staff had received training and support to enable them to carry out their role. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People were supported with activities and interests to suit them. Staff knew people’s likes and dislikes well. Staff told us the management team were approachable. The provider had systems in place to safeguard people from abuse.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 9 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to record keeping, the management of risk and cleanliness of the service at this inspection.Please see the action we have told the provider to take at the end of this report.

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.

Inspection carried out on 12 April 2017

During a routine inspection

The inspection took place on 12 April 2017 and was unannounced.

Broadway Lodge Residential Home is a care home providing accommodation and personal care for up to eighteen older people. At the time of our inspection there were 13 people using the service. The home is located in Fulford, on the outskirts of York. The home is owned by Mr & Mrs H Mohamudbaccus. Mrs Mohamudbaccus is also the registered manager of 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.

People told us they felt safe. The provider had policies and procedures in place to guide staff in safeguarding vulnerable adults from abuse, and staff we spoke with understood the different types of abuse that could occur and were able to explain what they would do if they had any concerns.

Support provided with medicines was recorded on medication administration records. Staff responsible for supporting people with medicines had received training and the registered provider was in the process of implementing a new medicines management policy.

The registered provider had a safe system for the recruitment of staff and was taking appropriate steps to ensure the suitability of workers. There were mixed views about whether there were sufficient staff available, especially at night. We found there were sufficient staff available to keep people safe and meet their needs and the registered provider agreed to keep staffing levels under review.

Risk assessments were in place to minimise the risk of harm to people, but not all of these had been written and reviewed in a timely manner.

Staff were able to demonstrate an understanding of the importance of gaining consent before providing care to someone and we found the service to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

People were supported to maintain good health and access healthcare services. We saw evidence in care files that people had accessed a range of healthcare support. People were supported with their nutritional needs.

Staff completed training and received on-going supervision to help them carry out their roles effectively. Staff meetings were also held regularly.

People told us that staff were caring and treated them with dignity and respect. We saw that interactions between people and staff were warm and friendly and staff knew people’s needs and preferences. Relatives told us staff kept them informed about any changes or concerns.

There was a quality assurance system in place, which included audits and satisfaction surveys, but we found the registered provider had not been proactive in driving improvement through the effective use of quality auditing systems. The registered manager had not met all legal requirements in relation to notifying the Commission of DoLS authorisations in place and displaying their most recent performance rating.

Feedback about the leadership of the service and the registered manager was positive and people were satisfied with the care they received.

Inspection carried out on 19 November 2014

During a routine inspection

The inspection of Broadway Lodge took place on 19 November 2014. The inspection was unannounced.

The home is registered to provide care for up to eighteen people. Sixteen people were present on the day of our visit. The home is owned by Mr & Mrs H Mohamudbaccus.  Mrs Mohamudbaccus is also the registered manager of 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.

People living at the home told us they felt safe. Appropriate notifications were made by the home where any potential safeguarding matters had been raised. Staff received training in safeguarding vulnerable adults and were clear of the action to take should a concern be raised.

People had risk assessments in their care files to help minimise risks whilst still supporting people to make choices and decisions.

There were sufficient staff on duty to care for people. People told us that staff were lovely, helpful and approachable and went out of their way when caring for them.

We found that people were recruited appropriately with all of the required documentation sought prior to their employment. This helps to ensure that only people safe to work with vulnerable adults are employed.

People told us they received their medication when they should. We observed staff administering medication in a supportive and professional manner. Records were well maintained and regular audits were completed.

People told us the service was effective. They told us that they could express their views and opinions and make suggestions and that these were responded to. We observed this during our visit.

The manager and staff understood the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They understood the importance of making decisions for people using formal legal safeguards. No recent applications had been made.

People expressed really positive feedback about the food provided. They told us that they could make suggestions to the menu and the owner would add any items of choice to the shopping list.

People told us their health needs were well attended to. They said they could see a doctor or other health professional when they needed to.

All of the people we spoke with said they were well cared for. They told us staff went out of their way to care for them and all said that it was a lovely place to live.

People expressed mixed views about the activities provided. Although a range of activities were taking place some people said that there wasn’t much to do. The registered manager may need to spend some time discussing this aspect of care with people.

People told us they could make choices and decisions regarding all aspects of their daily lives. They could choose when to get up, when they wanted a bath or shower, what they wanted to eat and how they spent their time.

People told us they were treated with dignity and we observed this throughout our visit.

People told us the home was responsive to their suggestions. They told us the providers spent time talking to them. This was observed throughout our visit.

People told us they would feel confident in raising complaints and we saw where complaints had been raised previously, these were recorded and responded to. None of the people we spoke with suggested any areas of improvement other than the activities.

People told us the service was well managed and run. They told us the owners were kind approachable people. Staff also confirmed this.

Staff told us they received good support which included regular  training and supervision. They said this helped them in their roles. They told us they worked well together.

There were a number of quality monitoring systems in place to seek the views of people living and working at the home. Where surveys have been given out a summary response should be collated and a copy given to people at the home. This would enable people to see what action the home were taking in response to their feedback.

Audits were completed so that the owners could continually evaluate and make improvements to the service. We saw where required  improvements had been recorded that relevant action plans were in place.

Inspection carried out on 7 November 2013

During a routine inspection

We used a number of different methods to help us understand the experiences of people who used the service. We spent time with people who used the service and observed the lunchtime experience and their interactions with staff.

We spoke in detail with five people who used the service and with members of staff including the two providers, four care staff and the chef. We spoke with four visitors to the service and with one social care professional. We also reviewed documentation including three care plans, service and maintenance records and kitchen records.

We found that effective management systems were in place to safeguard and promote people�s safety and welfare. Good professional relationships appeared to exist between people who lived at Broadway Lodge Residential Home and the staff team.

Care needs were discussed with people and/or their relatives and before people received care their consent was asked for. One person said, �Staff are lovely and always ask me about what I want to do. Another person said, �I appreciate all the care they give to me.�

People were provided with a choice of suitable and nutritious food and drink. Overall, we found that the service was clean and well maintained and one relative told us the service was always �Spotless.�

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Inspection carried out on 12 December 2012

During a routine inspection

When we visited Broadway Lodge the people who lived in the service spoke very highly of the care they received. They told us they felt respected and listened to. We observed staff treating people with respect and care. People were given opportunities to be involved in planning their own care and other things that happened in the home. One person who lived in the service told us "I do like it here. I get involved and they support me well".

We saw evidence that people were asked before any care was carried out and this was done in an appropriate manner. The service did not have signed consent forms but people had signed parts of their care plan.

We looked at most areas of the premises and found them to be clean and hygienic. We spoke with staff who showed a good understanding of infection control and we saw evidence that most staff had completed the relevant training. There were policies and procedures in place that were followed appropriately.

The management had carried out the necessary checks before employing staff and the recruitment and selection procedure was robust. We looked at the amount of staff that were working in the home and found this to be appropriate. Some staff did feel that they were sometimes very busy but people who lived in the service felt well looked after and able to get support when they needed it.

We saw that the storage and retention of paperwork was appropriate. All the documentation we looked at was detailed, accurate and up to date.

Inspection carried out on 8 March 2012

During an inspection looking at part of the service

People told us that Broadway Lodge was like home from home and that they were very well taken care of. Relatives also thought that the staff were marvellous and that care was very good.

Inspection carried out on 28 June 2011

During a routine inspection

We spoke with four people living at Broadway Lodge and all said they were happy living there. They made comments like �the care�s very good here. Staff definitely know what they�re doing�. And �you couldn�t wish for better people (staff)�. Another added �the care here is wonderful. There�s not a thing I could say against it�. And �I get every care�. Another told us �the manager is very good�