Broadoaks

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked at all quality statements for Safe at this assessment. The service was safe. The service followed recruitment procedures and enough staff were employed. Care staff completed appropriate training and their competency was regularly checked. People had care plans and risk assessments in place.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People experienced a manager who investigates complaints and says sorry when things go wrong. A relative told us the manager had identified the cause of a complaint, dealt with it and apologised for the distress caused. Another family member said, “I have never had to make a complaint but if I did, I feel they would respond.”

Staff told us they felt they could make complaints and would be listened to.

When incidents happen, they are investigated, and further actions are identified and shared with staff in team meetings and one to one supervision. There were processes in place to record incidents, complaints, and compliments however, one family member said they had not been made aware of the formal routes to make a complaint, but they would address with the manager if they had concerns.

People experienced a registered manager who works in partnership with other health professionals. One relative said, “The manager worked with the hospital to get all the information about assessed care needs. The transfer of care was brilliant. I have been able to speak with the new GP and district nurse.” A stakeholder said “Broadoaks are professional and easy to work with. They communicate their residents' health and wellbeing needs effectively and I am confident in the staff being advocates for residents that are not able to vocalise their own needs.”

The registered manager said, “We often have people come for respite care and work with them and their families to understand their needs and help them return back to their family home.”

The registered manager told us they would share information to support people to move safely between services.

A relative said, “The staff are caring and talk to people. Staff sit with people at lunchtime, they make sure they do everything they can. They appeared to be trained, they know what to do and how.”

Staff had a good understanding of signs of abuse and would not hesitate to raise a safeguarding alert to the registered manager if they suspected abuse. Staff did not tell us about other organisations they could report concerns to such as the local authority, CQC or the police if they were worried about how concerns were being dealt with internally. One staff member said, “I would report to head office, I am not sure where to report externally.” A stakeholder said, “I have no concerns about any aspect of the home or how residents are cared for.”

People were not unnecessarily restricted. People were engaged with and were positive about their care. We observed people taking part in activities and being actively encouraged to participate.

There were systems in place to record safeguarding concerns. The registered manager investigated concerns and had good internal records of actions taken, follow up discussions with staff and apologies to families. However, we found one safeguarding incident that had been resolved by the provider but not shared with the local authority safeguarding team. For this incident the CQC were also not informed by statutory notification. These are notifications the provider must make to the CQC for certain issues such as safeguarding concerns or serious injuries.

Two members of staff told us they have not read all care plans and risk assessments. When asked how do staff know people’s needs, staff said, “It’s detailed in care plans or we ask them.” Staff member told us, they are not directly involved with assessing people’s needs or updating records, but they can give feedback if they feel something needs to be changed.

Care plans had good detail within them to reduce risks, particularly around manual handling. A lot of detail to ensure the correct manual handling equipment is used. Although care plans were detailed to ensure correct manual handling equipment was used some other risks to people were not always fully assessed. For example, we noted a therapy dog, and a staff members dog regularly visit people in the home. This is not covered in a risk assessment. Some risk assessments for people who use wheelchairs did not detail if lap belts or footplates should be used. These are sometimes used to reduce the risk of injuries. Families told us they are kept informed of changes to peoples health needs but were not directly involved in care planning.

A stakeholder said, “The home is always presented in good condition with clean and appropriate facilities.” People experienced a modern and clean home with a bright and welcoming dining space, access to a courtyard garden and quiet areas to sit.

The registered manager ensured health and safety, and maintenance checks were regularly completed, and appropriate certification was in place. Personal emergency evacuation plans, and fire safety measures were in place. The registered manager told us they reassess the environment when they consider new people for the home. Staff were proud of the environment.

We noted that the first floor and ground floor had open access to a staircase at one end of the building. The registered manager told us the stairs do not currently pose a falls risk and that the stairs and access to them is assessed as new people move in or as peoples needs change. The provider had a risk assessment in place for stairs. The home environment was clean and pleasant. Rooms were personalised and the environment was calm. The main lounge was homely, and people seemed relaxed. The garden was well maintained and there were seasonal decorations around the home to help signify the changing in seasons.

The providers environmental risk assessment was not effective for the kitchen. The risk assessment stated access to the kitchen should be restricted to kitchen staff only. We found the kitchen was accessible via an open door that had been propped open when staff were not around. On the kitchen worktop there were two sharp knives left accessible. The kitchen also has internal rooms accessible through side doors that had been propped open. Through one of these doors there was a falls risk, down steps if a resident were to enter the doorway. We discussed this with the registered manager and staff who said, “The kitchen is not usually left open and knives when not in use are usually locked away.”

A relative said, “I couldn’t speak highly enough about their care. The support my [relative] has had has been remarkable. Staff do a fantastic job.” Another said, “They have been amazing since the moment we looked around.”

Despite some staff saying they had not read all care plans and risk assessments staff were able to explain peoples needs and preferences. One staff member said, “I keep up to date with changes when I have been off by checking the communication book.” Another said, “We are one big happy family, we can joke around. I am happy I have this job. I have learnt a lot here.”

At lunch time we observed someone being assisted to eat. The staff member left the person who they had been assisting to eat to answer the phone. This happened more than once leaving the person waiting. The person was then assisted by a member of the domestic team, who assisted with compassion. We checked the training, and this member of the domestic team had the appropriate training to be able to adapt in their role. Aside from leaving the person to answer the phone we observed staff treated people well, with kindness and attention. Staff made sure there was always someone in the lounge with people.

Not all staff have read people's care plans and risk assessments. Staffing levels were monitored by the registered manager and there were clear systems in place to ensure safe staffing in the event of any emergencies. Staff training was reviewed by the registered manager.

People experienced a clean and well presented home. Families told us the home is always clean.

Staff knew how to protect people from the risk of infections. The home was in very good repair with no environmental damage or smells.

The registered manager completed regular IPC audits and ensured PPE was available for staff to use. The kitchen was clean, foods in date with open dates and use by dates clearly visible. The home was in very good repair with no environmental damage or smells.

People told us they received their medicines safely and at the correct times. One person was able to explain their medicines to us and knew who has prescribed the medicines and why.

A staff member said, “I find myself being more aware of people's needs. I know the medicines they take well and what they are used for.”

Protocols for ‘as and when required medicines’ were not robust and lacked detail. For example, protocols failed to include how a person might communicate they need the ‘as required medicine’, or what the medicine is for. We found a protocol for creams with prescribed instructions recorded as, ‘as directed’, this does not detail where on the body the cream is for, or the amount to be applied. Staff were able to explain practises to manage peoples medicine and reduce risk of errors. Staff were aware of peoples rights to decline medicine and best practise to support this. Medicines were stored safely. Staff completed appropriate records when supporting people with their medicines and there were regular audits in place.