Broadacres Care Home

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. This is the first inspection of a newly registered provider. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Appropriate actions were taken to reduce the risk of similar occurrences in the future. Lessons learned were identified, and reflective practice exercises were completed to evaluate what could have been done differently and to identify opportunities for continuous improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider had a process to support people who transferred to other services, including hospital admissions, to ensure that all relevant information accompanied them. This information included their life history, medical conditions, current medications, and a summary of their care plan, helping to promote continuity of care and support their individual needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People were protected from the risk of abuse. Staff received training in safeguarding and understood how to recognise and report abuse. The management took appropriate and timely action to keep people safe.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The manager maintained a record of DoLS and care plans included information about mental capacity.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people's care were identified and managed to keep safe. Risk assessments were in place to ensure care and support was delivered safely. People were supported by staff who knew them well and understood their needs.

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 garden area required attention to enhance the environment, radiator covers were in need of repair or replacement. The management team were in the process of refurbishing parts of the service to improve the design for people living at the home. An action plan was in place and issues were being addressed. Personal emergency evacuation plans [PEEP’s] were in place to ensure people were supported appropriately to exit the home in an emergency. Routine maintenance checks were completed, and equipment was serviced in line with regulations

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We observed staff were busy but were able to respond to people’s needs in a timely way. Although some people and relatives felt there were occasions where there were not enough staff around. We spoke with the management team and they told us they completed a dependency tool to identify the number of staff required each day and night. This was reviewed monthly or sooner if needed. The provider had a recruitment process to support them in recruiting suitable staff. We saw pre-employment checks were carried out prior to staff commencing their role at the home. Staff received supervision and had opportunities to reflect on their practice.

The provider did not always assess or manage the risk of infection. We carried out a tour of the home and found some areas in need of a deep clean. Some areas required repair to ensure they could be cleaned effectively. For example, some tiles in the sluice area were chipped and cracked, some toilets had chipped paint work and tiles, and fabric chairs in the lounge were difficult to keep clean. There was a programme of refurbishment, and all carpeted areas were due to be replaced with easy to clean flooring.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff received training and had competency checks to ensure they had the knowledge to administer medicines safely. People generally received their medicines as prescribed; however, there were some recording inconsistencies relating to the application of topical creams. In addition, although some people were prescribed medicines in patch form, records did not always demonstrate that patch rotation had been completed, and body maps did not consistently identify application sites clearly. The management team were aware of these issues and had already begun implementing improvements. Medication management within 1 unit demonstrated stronger practice and reflected the positive actions taken by the management team to address and improve the recording and monitoring processes.