Broughton Lodge

Updated 18 May 2023

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.

Inspection team

The inspection was carried out by 1 inspector 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. The Expert by Experience contacted people's relatives by telephone to request their feedback.

Service and service type

Broughton Lodge 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. Broughton Lodge is a care home without 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all of this to plan our inspection.

During the inspection

We spoke with 4 people who used the service and 13 relatives. We spoke with 5 members of staff including the registered manager. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed a range of records. This included 3 people's care records and 5 people's medicines records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service and quality assurance were reviewed including accident and incident records and audits. We sought feedback from professionals who work with the service.

Updated 18 May 2023

About the service

Broughton Lodge is a residential service providing personal care for up to 18 older people some of whom are living with dementia. The service consists of an adapted building, which includes individual bedrooms, communal spaces and an accessible outdoor space. At the time of our inspection there were 16 people using the service.

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

People told us they felt safe with the care and support they received. However, despite mostly positive feedback, we found shortfalls with the management of people’s risks and quality assurance systems which placed people at increased risk of harm.

Systems in place to monitor the quality and safety of the service did not identify and address the shortfalls we found during the inspection.

Not all risks to people had been sufficiently assessed. People received their medicines safely and as prescribed, however we found some minor issues with the management of medicines.

Staff had received safeguarding training and understood their responsibility to report any concerns. Appropriate staff recruitment procedures were in place; however, recruitment records were not always well documented. There were enough staff to keep people safe and meet their needs. Staff followed safe infection prevention and control measures.

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.

Staff told us they felt supported and morale within the staff team was good. People and their relatives spoke positively of staff and told us they were satisfied with the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published February 2019). There have been two targeted inspections since this inspection, published July 2020 and February 2022. These did not change the rating.

At our inspection published July 2020 we recommended that the provider review the published guidance on developing care plans for people with specific behavioural support needs. At this inspection we found sufficient action had not been taken in response to this recommendation.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement

We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.