Broadoak Manor Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was in breach of legal regulation in relation to consent.

This service scored 38 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

For example, when English was not a person’s first language, communication care plans lacked information about how best to communicate with the person, and there was no evidence translators had been used or considered where appropriate.

People’s care plans did not always contain detailed information about their specific needs. For example, there was no guidance for staff on how to support a person experiencing emotional distress, or how to meet particular health needs. People were at risk of their needs not being met.

However, we found most staff knew people and their needs well. Family members told us they were kept up to date with changes in their relative’s needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

The use of restrictive interventions to manage people’s behaviours of concern were not always assessed, planned, or approved in accordance with the MCA or DoLS. This meant people’s human rights were not always protected.

Risk assessments, care plans and records related to the use of restrictive practices were not always complete, up to date, or sufficiently detailed to support their safe and lawful use.

We were not assured people’s nutritional needs were met in line with their assessed International Dysphagia Diet Standardisation Initiative (IDDSI) levels. The IDDSI framework is a system used to describe how soft or thick foods and drinks should be for people with swallowing difficulties. Inconsistencies across records, care plans and information available in the kitchens did not demonstrate people consistently received the correct diet for their assessed needs.

Staff did not always document the correct levels drinks had been thickened to for people at risk of choking. Therefore, we were not assured people had their drinks thickened as prescribed.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

In general, staff felt teams within the home worked well together to support people and meet their needs. However, this was not always reflected in documentation, for example, we identified gaps and discrepancies in fluid and food recording, and medication administration.

Feedback from one professional was, “Communication has always been positive, and we work well together to support patient flow both into the unit and safely back home.”

The provider did not always support people to manage their health and wellbeing. Gaps in recording and monitoring made it difficult to determine whether all people were consistently supported to live healthier lives and manage their health effectively. People had access to external healthcare professionals, such as GPs. The staff in the step-down unit had built good relationships with external professionals, and people had access to treatment where required, for example, physiotherapy.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves.

Gaps and inconsistencies in records made it difficult to effectively monitor people’s care and ensure the care delivered was safe and effective in promoting positive outcomes.

For example, for one person with wounds, there were gaps in their repositioning charts, and repositioning was not delivered in line with their care plan. Repositioning is a key part of wound care, with the purpose to relieve pressure, protect damaged skin and prevent further tissue breakdown. Gaps in repositioning placed people at risk of further deterioration.

For another person who was recorded as being at risk of dehydration, fluid charts showed large gaps when drinks were neither offered nor recorded. In addition, records for another person showed inconsistencies, such as drinks being recorded as offered at the same time the person was documented as sleeping. These records did not provide assurance people received adequate hydration, or staff were accurately monitoring fluid intake.

Records for people at risk of choking and on modified diets were not accurate in recording their required food texture levels. Where discrepancies were recorded, it was unclear what action had been taken, to ensure oversight of people’s dietary needs.

The provider did not tell people about their rights around consent and did not respect their rights when delivering care and treatment.

The use of restrictive practices was not always carried out in line with the MCA and DoLS. Some restrictive interventions were used before a mental capacity assessment, best interest decision, or DoLS application for authorisation had been completed.

In addition, mental capacity assessments and best interest decisions were not always in place for specific decisions including those which restricted a person’s movement. For example, one person used a postural chair with a lap strap, but there was no reference to this in their care plan, and no mental capacity assessment or best interest decision had been completed for its use.

For people whose first language was not English, mental capacity assessments did not reference the use of a translator, and it was therefore unclear whether the assessment had been conducted in a way the person could fully understand.