Broadway Halls Care Home

Updated 29 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors, an assistant inspector, a specialist advisor who was a qualified nurse and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Broadway Halls is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Broadway Halls is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post since May 2022 and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We reviewed on-going monitoring such as information received. We used all this information to plan our inspection.

We used all this information to plan our inspection.

During the inspection

We spoke with eight people who used the service and eight relatives about their experience of the care provided. We spoke with nine members of staff including the manager, the regional support manager, the deputy manager and the clinical lead.

We reviewed a range of records. This included nine people's care records and multiple medicines records. We looked at five staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 29 February 2024

About the service

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.