8 September 2022
During an inspection looking at part of 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.