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Reports


Inspection carried out on 11 June 2019

During an inspection to make sure that the improvements required had been made

About the service

Broadoak Manor Care Home is a care home providing personal and nursing care to 110 people aged 65 and over at the time of the inspection. The service can support up to 120 people.

The care home accommodates people across four separate houses, each of which has separate adapted facilities all on ground floor level. Three of the houses support people with personal care and nursing needs.

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

Systems in place to monitor the quality of people's care records were not always effective as they did not always identify or address areas of improvement needed. We have made a recommendation in the Well-led section of this report.

People’s needs were planned for and regularly reviewed. Improvements had been made to the prevention and monitoring of people pressure ulcers and wounds. Activities were planned and available for people to join in with. A complaints procedure was in place and accessible to all.

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 8 December 2018). The Responsive outcome area was rated as requires improvement as we identified a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection improvements had been made however, we have made a recommendation in relation to the monitoring of people’s care records.

Why we inspected

We carried out an unannounced focused inspection of this service on 11 June 2019. A breach/ breaches of legal requirements was/ were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Responsive and Well-led which contain those requirements.

The overall rating for the service remains good. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Well-led section of this report.

The ratings from the previous comprehensive inspection for those Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains Good. This is based on the findings at this inspection.

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

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 26 September 2018

During a routine inspection

This inspection took place on the 26 September and 5 October 2018. Both visits were unannounced.

Since the previous inspection in July 2017 the registered provider has changed from BUPA Care Homes Limited to HC-One Oval Limited.

Broadoak Manor Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Broadoak Manor accommodates up to 120 people in four single storey accessible houses. Three houses provide personal care and nursing and the forth provides personal care only. Older people living with dementia and physical health needs are accommodated at Broadoak Manor.

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.

At the previous inspection we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because audit systems in place were not always effective in identifying issues relating to equipment on two houses not being cleaned which posed an infection risk to people. In addition, two bathrooms were left unlocked which gave people using the service access to hot water which put them at risk from scalding themselves. During this inspection we found that improvement had been made.

During this inspection we identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because detailed and effective records were not always maintained.

A recommendation has been made in this report that the registered provider reviews the current arrangement for mealtimes to ensure that people experience the best possible outcome from their dining experience.

We have made a further recommendation that the registered provider maintains regular monitoring of care planning and wound care documents to ensure that they are detailed and effective at all times.

Systems and procedures were in place in relation to the Mental Capacity Act 2005. Records demonstrated that where required, applications had been made on behalf of people in relation to Deprivation of Liberty Safeguards.

People had freedom of movement around the service and told us that they had a choice where they spent their time, and what time they went to bed and got up.

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Policies and procedures were in place and available to all staff. The service was currently transitioning documents from the previous registered provider to the current registered provider's information.

An activity co-ordinator was employed at the service. People told us they had a choice of if they wanted to participate in activities.

People were encouraged to maintain their independence wherever possible.

People using the service felt safe and told us that they knew who to speak with if they had any concerns.

A complaints procedure was in place and people knew who they would speak to if they wanted to raise a complaint.

Systems were in place to ensure that people's medicines were safely stored and to help ensure that people received their medicines when they needed them.

People told us that staff delivering their care and support were caring and respected their dignity.

People had a choice of menu during mealtimes and regular drinks and snacks were available; they were happy with the food they were served.

Inspection carried out on 20 July 2017

During a routine inspection

The inspection was unannounced and took place on the 20 July 2017. In January 2017 the service re-registered with the CQC and therefore the service had not been inspection under this registration.

Broadoak Manor is registered to provide accommodation and personal care for up to 120 people. The service specialises in providing nursing care to older people living with dementia and physical health needs. The service consists of four houses, three of which provide nursing care, whilst another provides residential care for people living with dementia. At the time of the inspection there were 116 people using the service.

There was a registered manager in post within the service who had been registered since February 2017. 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.

During the inspection we identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because audit systems were not always effective at identifying issues within the service. Equipment in two of the units had not been cleaned which placed people at risk of infection. We also identified two staff bathrooms that had been left unlocked and accessible to people, within which water exceeded safe temperatures. This placed people at risk of scalding themselves.

People’s care records contained details regarding their sensory needs and in some examples we observed people wearing their glasses and hearing aids as required. However, in one unit one person was unable to locate their glasses. In the same unit there were eight pairs of glasses being stored in the lounge, however staff did not know who these belonged to, and the lenses were scratched and dirty. We have made a recommendation to the registered manager around ensuring people’s sensory needs are met consistently.

Activities were available to people. However some people commented that they sometimes felt bored, whilst other people told us there was plenty to keep them occupied. This pointed at a disparity between the provision of activities in the different units. During the inspection we saw examples of activities taking place, and positive social interactions between staff and people. We raised people’s comments with the registered manager so that she could look into this.

People received their medication as prescribed. We looked at a sample of medication in two units and found that the quantities being held were correct. Staff signed medication administration records (MARs) as required to show that medication had been administered. Medication was being given in a timely manner, and clear instructions were available for staff on when to administer this.

There were sufficient numbers of staff in place to meet people’s needs. We checked staffing rotas and identified that there were consistent numbers of staff in post for each shift. Some people commented that they sometimes had to wait if they pressed their call bell, however they told us they did not have to wait too long and they received the support they needed.

Recruitment processes were robust and helped ensure staff were of suitable character to work with vulnerable people. Checks were completed prior to new staff being employed to make sure they did not have a criminal history, or were not barred from working with vulnerable people.

Staff had received the appropriate training required for them to carry out their role effectively. For example they had completed training in areas such as moving and handling, dementia and safeguarding. People also commented positively on the support they received from staff, and we observed examples of good practice in their interactions.

People were supported to have maximum choice a