Archived: Broadacres

We spoke with the assistant manager, three care staff and five people who used the service. The service did not have a CQC registered manager in place. The assistant manager told us that the provider was in the process of appointing someone.

We reviewed the care records for four people. We also reviewed a selection of other records. These included staffing rotas, minutes from meetings and audit results.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA), 2005, and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The MCA provides a framework to empower and protect people who may make key decisions about their care and support. The DoLS are used if extra restrictions or restraints are needed which may deprive a person of their liberty. We saw evidence that the provider had acted in accordance with the law in relation to the MCA and DoLS. People who used the service had received appropriate mental capacity assessments and a number of 'best interest' decisions were recorded. At the time of this inspection no person living in Broadacres had a DoLS authorisation.

Risk assessments had been completed for people and were reviewed on a monthly basis. The purpose of these was to minimise the risks to people in relation to their needs.

There were effective systems in place to reduce the risk and spread of infection. The provider had an infection control policy and we saw that this was followed by the different staff groups. Hygiene and cleanliness were monitored on a daily basis.

People who used the service told us that they felt there were enough staff on duty to meet their needs at all times. We reviewed four weeks of staff rotas and noted that the numbers of staff on duty reflected the provider's staffing requirements.

There were effective systems in place to record and investigate accidents and incidents. We saw that the provider took actions to help reduce the likelihood of repeat occurrences.

The provider had effective arrangements in place to manage foreseeable emergencies. These included plans in relation to fire and the loss of utilities.

Is the service effective?

People's needs were assessed, and care and support was planned and delivered in order to meet these needs. Nationally recognised tools were used in the assessment of people's needs. These included the 'Malnutrition Universal Screening Tool' (MUST) for people at risk of malnutrition or obesity, and the 'Waterlow Pressure Area Tool' that helped to determine whether people were at risk of developing pressure sores.

We saw evidence that people's needs were being met. The care and support delivered by staff reflected what had been documented in people's care plans. People's records were up to date and included any changes in their needs.

During the review of four people's care plans we saw evidence that the provider worked closely with other health and social care professionals. These included physiotherapists, dieticians and district nurses. This meant that people received care from a multidisciplinary team that helped to address all of their needs.

Is the service caring?

We spoke with five people who used the service and received positive comments from each person. One person said, 'I am happy here and the food is excellent. The staff are lovely.' Another person said, 'I get well looked after. I choose to stay in my room most of the time but there are things to join in with if you like. The staff are excellent; very kind. I have no complaints or concerns.' A third person said, 'I like to go down to the (service's) pond and sit there. It's lovely living here. I have no complaints.'

During our inspection we found that people were supported by compassionate and attentive staff. People told us that they chose when they wanted staff to assist and support them. An example of this was people choosing whether they had a bath or shower in the morning or the evening.

It was evident that the staff knew the needs of people well. People's privacy and dignity were maintained at all times during our inspection.

Is the service responsive?

People's care plans responded to and reflected their physical, emotional and social needs. People's likes, dislikes and preferences were recorded. The care and support that people received met their preferences. People could choose how they wished to spend the day and the staff respected their decisions. People had access to activities that they enjoyed. The people who we spoke with told us that their relatives and friends were always welcomed at Broadacres.

We saw evidence that learning from complaints and concerns took place. Complaints were audited on a monthly basis and the provider took account of them to help improve the quality of the service.

Is the service well-led?

The service did not have a CQC registered manager in place. The assistant manager told us that the provider was in the process of appointing someone. They told us that the provider had written to the people who used the service to explain why there wasn't a registered manager in post.

The assistant manager told us that they managed the day to day running of the service. They said that they were supported by a care manager and administration team. All of the care staff we spoke with told us that they felt well supported. An agency care worker, who worked regular shifts at the service said, 'I love working in this home. I have been really welcomed and feel part of the team. Everyone works well together and the assistant manager is fantastic.'

The staff we spoke with could tell us about the quality assurance processes that were in place. These included regular audits of all aspects of the service. Satisfaction surveys had been conducted and the provider had sought the views from different groups of people. These included people's relatives and other health and social care professionals who visited the service. Action plans had been formulated and implemented for any areas of the service that required improvement.

The staff we spoke with understood their roles and responsibilities. There was a senior care worker on each shift and staff told us that they would escalate any concerns that they had to this person. There was an on-call system for staff to contact a senior person or manager out of hours.

Everyone we spoke with was very complimentary about the meals provided and made comments such as, 'The meals are very good ' too good in fact, I'm putting on weight!' 'very good food - they've got the chefs well trained' 'there is always a good choice and you can ask for different things ' you're not just stuck with what's on the menu.'

People we spoke with told us that they were supported to take their medicines at the prescribed times and we noted clear records of any allergies where it was appropriate.

People told us that they believed the staff were supported well by the manager and that they received good training, which enabled them to carry out their duties professionally and competently.

Staff told us that they were happy in their work, felt confident in carrying out their duties and knew each of the people well that they cared for and supported..'

People we spoke with told us that they felt able to raise any concerns or make a complaint if they needed to. One person said, 'I've had one or two occasions when I've needed to mention something to the carers and they've always put things right. I've never had the need to actually make a complaint.'

This person also told us that, although they were diabetic, this had not been a problem as the cook catered for people's individual dietary requirements.

When we asked, one person we spoke with told us that they were always treated with dignity and respect.

We saw that a number of in-house activities had been arranged for December and we also saw that regular visits were made to the home by a hairdresser, chiropodist, manicurist and physiotherapist.

During our tour of the premises, we saw that people were provided with spacious and comfortable private accommodation and shared communal areas. We also saw that all areas were cleaned and maintained to a very high standard.

One person we spoke with showed us their call bell pendant and told us that staff usually responded very quickly when they were needed.

Overall, we saw that there was a balanced complement and skill mix of staff in sufficient numbers to oversee the care provision and there were good staffing levels in respect of people employed to cover specific roles such as cooking, serving, laundry, housekeeping, maintenance and administration.

There were a number of systems in place to assess and monitor the quality of service provided at Broadacres.