25 January 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 18 January 2022 and was announced. We gave the service one day's notice of the inspection.
25 January 2022
The Inspection took place on 29 March and 10 April 2018 and it was unannounced.
Broomhills is a ‘care home without nursing’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service is registered to provide care and accommodation for up to 47 older people some of whom may be living with dementia and/or a physical disability and/or a sensory impairment. Although the service is registered to care for 47 people, the registered manager has reduced the number of rooms in use and there were 42 people living in the service during our inspection visits. They told us the service was full and that they had a waiting list.
At the last inspection, the service was rated good. We recently received some anonymous concerns that the service was not reporting incidents appropriately and we also had concerns about the number of un-witnessed falls that had taken place during the night. At this inspection, we did not find any evidence to support the allegation that incidents were not reported appropriately. The registered manager had put in place a system to minimise the risk of falls at night. Therefore, we found the service remains good.
There was a registered manager in post. 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 received their care and support safely. Staff knew how to support people and protect them from the risk of harm. Risks to people’s health and welfare were well managed. The service recruited staff safely and employed sufficient numbers of staff to meet people’s assessed needs.
People received their medication safely and as prescribed and the records were of a good standard. Staff had received regular updates in training and checks to ensure that they were competent to administer medication safely. The service was well maintained, clean and hygienic. Staff had been trained in infection control and had a good knowledge of infection control procedures.
People’s needs had been fully assessed and care plans had been regularly reviewed and updated to ensure they continued to meet their needs. Staff were well trained, supported and supervised and knew how to care for people effectively. People were offered a choice of fresh home cooked meals in sufficient quantities to meet their nutritional needs. The fruit and sweet stalls offered them additional snacks and there were cup drinks available 24 hours a day. Staff worked with health and social care professionals to ensure that people’s healthcare needs were fully met.
The service worked in line with other legislation such as the Mental Capacity Act 2005 (MCA) to ensure that people had as much choice and control over their lives as possible. Appropriate assessments had been carried out in line with legislation. The service had made appropriate requests for authorisation when people were deprived of their liberty, People’s independence was encouraged while minimising any risks to help keep them safe.
People were cared for by kind, caring and compassionate staff who listened to them and made them feel that they mattered. Staff treated people with dignity and respect and ensured they had the privacy they needed. People and their relatives were fully involved in making decisions. Advocacy services were available if people needed them. An advocate supports a person to have an independent voice and enables them to express their views when they are unable to do so for themselves.
People received personalised care that was responsive to their needs. Care plans and daily notes were very detailed and informative and were kept up to date. People had good community links and were kept occupied with a range of indoor and outdoor activities and events. The complaints procedure was good and complaints had been fully investigated and addressed.
People and their relatives had confidence in the registered manager and knew them well. Relatives said they felt that the registered manager was very good at their job. Staff felt supported and shared the manager’s vision to provide people with good quality care. There were effective quality assurance systems and processes in place that identified and actioned the improvements needed. Confidential information was stored safely in line with data security standards.
Further information is in the detailed findings below.