Broadway Halls Care Home

Broadway Halls is a residential care home providing personal and nursing care to up to 83 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 53 people using the service.

Broadway Halls accommodates people across four separate floors, each of which has adapted facilities.

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

People’s medicines were not always managed safely. Several medicines administration records contained unexplained gaps in recording.

Risks to people’s health and safety had not always been identified and managed. People had not always received consistent support to reduce their risk of pressure sores.

The provider’s recruitment practices needed to be improved.

The provider’s systems and processes to assess and monitor the service were not always effective or robust to enable improvements to take place.

People told us they felt safe. Staff sought consent prior to carrying out care tasks.

There were systems and processes in place to protect people from the risk of abuse. When things went wrong, the manager carried out investigations and lessons learnt were shared with staff. Relatives told us they were informed when things went wrong.

People were supported to eat and drink. However, feedback from people about the food was that it could be better.

Staff worked with other agencies to ensure people received a joined-up approach to their care.

Staff told us they felt supported by the management team and people spoke positively about the new manager.

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 and update

The last rating for this service was good (published 14 May 2019).

Why we inspected

This inspection was prompted by concerns we received in relation to inadequate staffing levels, wound management, record keeping, pressure relief and incidents not being shared with relevant agencies. We undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Broadway Halls on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the management of medicines, staffing and the overall governance 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, which will help inform when we next inspect.

Broadway Halls Care Home is a care home providing personal and nursing care to 83 people. The home is purpose built with four separate units. Care and support was provided to people living with dementia, nursing needs and personal care needs. At the time of this inspection 57 people lived at the service.

We found the following examples of good practice.

¿ On arrival visitors were asked to consent to a lateral flow test (LFT). Professional visitors were asked to provide evidence of their vaccination status. Visitors would be provided with appropriate personal protection equipment (PPE), if required.

¿ There were hand washing facilities available at the point of entry for visitors to wash their hands.

¿ There was a booking system in place for family members to use. This could be accessed directly by family members or they could contact the home directly and arrangements could be made through the administration team.

¿ There was additional cleaning of touch points in communal areas to mitigate the risk of cross infection.

¿ The service kept in contact with family members through essential visits, social media, phone calls, window visits, a separate family visiting area and a visiting pod completely detached from the main body of the home.

¿ Staff adhered to PPE guidance and practices. There was a plentiful supply of PPE at all PPE stations situated close to people’s bedrooms.

¿ Staff continued to support people to access healthcare services. Arrangements were in place should people need to attend hospital and return to the home safely.

¿ The service had a separate visiting pod for relatives and friends which enabled them to see their loved ones safely.

¿ Laundry and clinical waste was managed in line with the latest guidance.

People’s experience of using this service:

¿ People told us they felt safe living at Broadway Halls Care Home.

¿ Staff received safeguarding training and were knowledgeable about abuse and how to report any concerns. This meant people were protected from potential harm.

¿ People were supported to be as independent as they were able to be.

Risk assessments were in place which reflected people's needs and allowed staff to monitor people's safety.

¿ People were supported with their medicines on time by trained staff who knew them well.

¿ People had personalised care plans which were reviewed when their needs changed. This enabled people to be supported in a way which they had chosen.

¿ People were supported by staff who were recruited safely and had received training to enable them to meet people's needs.

¿ People had access to health professionals to ensure effective and timely care.

¿ People were supported to maintain a balanced diet. People were given additional support were this was required to ensure they ate and drank well.

¿ People were supported to make decisions around their care. This enabled people to choose how and when care was delivered.

¿ People were supported by staff which were caring and compassionate.

¿ People's privacy, dignity and independence was respected and promoted.

¿ People were supported by the service to give feedback about their care and support. The service took action when required to improve people’s experience of care.

¿ The service had a transparent culture of learning lessons when things went wrong.

¿ People felt able to speak to the management team about concerns regarding their care. People told us managers were approachable and took the time to listen to people.

Rating at last inspection: Broadway Halls Care Home achieved a rating of ‘good’ throughout during their last inspection which was published on the 7 November 2016.

Why we inspected: This was an unannounced, scheduled inspection.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

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

At our last inspection in June 2015 we found improvements were needed to staffing levels to meet people’s changing needs. Risks to people’s safety had not always been identified and managed and incident reporting was not robust. People’s medicines were not always managed safely. The provider sent us an action plan and at this our most recent inspection we found that the provider had made the improvements needed.

Broadway Halls Care Home is a care home that provides personal and nursing care for up to 83 people. The home is purpose built with four separate units. Care and support is provided to people with dementia, nursing needs, and personal care needs. At the time of our inspection 79 people lived at the home..

A registered manager was 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 told us that they felt safe and staff had been trained to recognise and report harm or abuse. We found improvements regarding the medicine management systems that confirmed that people had received their medicine safely. The management of risks to people’s safety such as falling, losing weight or developing pressure sores had improved and staffing levels had improved to ensure that people were safe and received the care and support that they needed.

Staff had an induction into their role and support and training was in place to support them with developing the skills to meet people’s needs effectively. Staff were aware of the Mental Capacity Act 2005 and the importance of seeking people’s consent. They had received training in the Deprivation of Liberty Safeguards (DoLS) and understood how to support people who lacked capacity. People told us they enjoyed the meals and we saw that their dietary needs were identified and monitored. People were supported to maintain their health and had access to a range of health care professionals.

People described staff as kind, patient and respectful. People’s privacy and dignity was protected by staff who understood how to promote these aspects of people’s care. People were involved in planning their care and their preferences were respected. People told us that they were very happy at the home and were happy with the care provided. Relatives told us the staff team always demonstrated consideration for people’s needs.

Everyone we spoke with commented positively on the variety of leisure activities available which included making good use of links with community amenities. A complaints procedure was available for people to use and people told us that they would be happy to use it if they had the need.

People and their relatives consistently described the service as being well managed. The standards within the home were regularly monitored and had been effective in identifying and making improvements. People’s views about the quality of the service were captured by way of them completing questionnaires.

Most of the people and the relatives we spoke with told us they were happy with the care and support provided. One person said, 'The care here is great, and the staff are brilliant.' Another person told us, 'It is very nice here; warm and comfortable like being at home.' A visitor told us, 'My relative loves it here. If they had a complaint she would say so.' A visiting professional told us, 'The staff respect people and provide good care. The home is maintained to a high standard.'

We found that people's needs were assessed, and care plans were developed in consultation with people or their representatives. Staff spoken with were able to tell us about people's needs. This ensured they received support in a way they preferred.

We found that staff were clear about the action to take should they become aware of an allegation of abuse. We saw that staff had training to assist them in protecting people from harm.

We found that procedures were in place to ensure that only suitable staff were employed to work at the home.

We found that there wasn't sufficient number of staff available to meet people's care needs specifically on the nursing unit.

We found that systems were in place for assessing and monitoring the quality of the service provided.

The home was split into four units. There were two residential units, one unit for people with dementia, and one unit for people who required nursing care. We spoke with seven people, five relatives, six staff, the deputy manager, and the home manager.

We found that staff obtained consent from people or their relatives before delivering care. Arrangements were in place for people who did not have the capacity to consent.

People's care records were detailed and reviewed on a regular basis. We found that people had access to other healthcare professionals. This meant that people received care that met their needs. One person said, 'You can see a doctor anytime, or a chiropodist.'

We found that arrangements were not in place to ensure that people received their medicines in a timely and safe manner.

We found that there were enough skilled staff to look after people's needs. One person told us, 'Staff are great, we can press the bell and they come and help us.'

We found that people were encouraged to complain, and that these were taken seriously. One person said, 'It is great here, I cannot complain at all.'