Broadbridge Park

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

The overall rating for this key question is good. People were protected from the risk of abuse, staff understood how and who to report concerns to internally and externally of the service. Staff and management learned from safeguarding concerns and adverse events. Safeguarding concerns were responded to appropriately and lessons were learned to avoid reoccurrence. Where identified, additional training was sought for staff following concerns and health and social care professionals provided advice to drive improvements to the service. People were involved with planning their care and support, including managing risks. Where people were unable to contribute to their care planning, people’s relatives were consulted. Staff were provided with up to date guidance to support people safely and in line with their wishes. There were enough trained and skilled staff on duty to support people. The provider followed safe recruitment practices and staff were regularly supervised. Staff received training relevant to their role and were able to request further training for ongoing development or promotions. People celebrated staff’s attitude and achievements and voted for a ‘shining star of the month.’

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at the service, people’s relatives also said they felt their loved ones were safe; they told us if they were concerned they would speak with staff or management. A relative gave an example of where they had raised concerns and were satisfied with the outcome. One person commented, “I feel very safe, the staff look after me.” A relative said “I do feel [person] is safe there. He is cared for 24/7 and staff are always there looking out for the residents.”

Staff demonstrated their understanding of types of abuse, they told us what they would watch out for if they were concerned about people and who they would report concerns to both within the service and externally if needed. A staff member told us, “If I was worried I would go to senior or deputy or manager. If needed I would approach [regional manager], we have whistle-blowing telephone numbers. If I thought it was necessary I would go to CQC.” The registered manager told us about how lessons were learned following safeguarding concerns, they said, “I investigate where it is applicable, I looked at what went wrong and how we can put it right.”

We observed staff supporting people in a kind and caring manner, people looked relaxed in the company of staff. Although some people had deprivation of liberty (DoLS) authorisation in place, people could freely to go out in the garden and their movements were minimally restricted. We saw posters where people and staff were sign posted on how to raise concerns.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, this is through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Staff understood and worked within the principles of the MCA. DoLS applications were completed in people’s best interests. Where people had a DoLS in place, conditions to their authorisations were being met, for example, medicine reviews were conducted on a regular basis. The provider’s safeguarding policy was clear for staff to understand should they have a safeguarding concern. Safeguarding concerns were investigated and lessons learned were shared with staff through meetings, where needed, additional training had been arranged. Actions taken were monitored by the management team to ensure learning had been embedded. For example, following a concern it was identified that record keeping and escalation needed improvements, the management team now audited records daily.

People and where appropriate, their relatives were involved in formulating risk assessments and care plans so staff were aware of how they wished to be supported. A person told us, "I have some help, on a good day I can do most things myself, on a bad day I just let the staff know and they are happy to help. I just tell them what I need doing. This is all in plan. They asked me questions about what I need help with and put what I have said in the plan." A relative commented, “I have been involved in care planning and discussions. We have updated it a few times now. I tend to deal with it rather than her due to her dementia.”

Staff told us care plans and risk assessments were accessible and contained enough detail on how they can safely support people. A staff member told us how they supported a person to take risks. They said, “We have a resident who likes to go and take themselves off for a walk, you let them go but go off to find them, I poke my head round the corner to check they are safe. They have capacity and can make these decisions.” A member of the management team told us about how they had oversight of accidents and incidents. They said, “Once a month, we do a falls audit, we look at the falls matrix, look to see days, times, places and person. Everyone who is medium or high risk on their falls risk assessments automatically have a multi-factorial assessment in place, if fallen or not. Before this, or after the second fall a multi-factorial risk assessment is put in place and a referral to falls team, then raised to GP for medicine reviews.”

We observed people were supported by staff to move and position in line with their care records. Where risks were identified, such as, people who were at risk of falling from bed, consideration had been given to manage the risks with minimal restrictions. For example, people were not always restricted by bed rails, however, staff had placed safety mats either side of the bed, beds were set at a low level and bed sensors were in place which helped people remain safe yet with freedom of movement. People used various walking aids to suit their abilities, one person who used a wheelchair preferred to use their feet to move the wheelchair from room to room, a risk assessment was completed for this which promoted their wishes to be independent and enabled positive risk taking.

Risks to people’s health were assessed and plans were in place to mitigate risks. For example, a person wished to smoke cigarettes, staff assessed the risk with the person to enable them to smoke safely. People who were at risk of pressure damage to their skin had appropriate risk assessments in place and care plans to guide staff on how to support them. Some people required staff support to reposition so they could relieve pressure to their skin. People’s care plans reflected the frequencies of position changes and associated care charts confirmed staff were following guidance. Some people lived with diabetes; their care plans contained information for staff on how to support them. Care plans contained guidance on what signs to watch out for and what to do in the event of hyper or hypoglycaemic attacks.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives provided positive feedback about the staff and told us there were enough trained and skilled staff to meet their needs. A person said, “They come when I ring the bell, I don’t often have to wait, they give me a bed pan.” A relative commented about staff training and practices and said, “I do think the staff know how to support people who have dementia. They seem to know how to talk to them and calm them down when needed. You see it all the time, using distraction techniques, talking quietly and stroking their arm or back. They are very good.”

Staff told us there were enough staff on duty to meet people’s needs. Staff spoke highly of the support and training they were provided. Comments included, “On average there are enough staff, it is not overrun nor understaffed, they don’t wear us out, we still get our breaks. In the morning, we have enough time for the residents, we know their patterns and when they want things done. The activities team as well are here. Whilst we are busy with personal care someone else is with them chatting, in the bistro. It’s quite a lovely home here.” Another staff member said, “After the training, they don’t just come and teach and go, they teach and do practical examples, like the importance of slide sheets, they showed us and they saw us practice, we got to experience that too. They checked to see we were using it properly so we can use it on the residents.”

We observed enough skilled and experienced staff to support people, staff promptly responded to people’s requests. Staff had enough time to support people with their meals and well-being co-ordinators spent time with people providing social activities. The staffing team was consistent, many staff had worked for the service since it opened, this meant staff knew people and their preferences well. Staff supported people at their own pace throughout our assessment and demonstrated their knowledge and correct techniques.

Staff were recruited safely; prior to their employment appropriate checks had been carried out to include references, the right to work in the UK and PIN number checks for registered nurses. A training matrix was continually updated so management were able to identify when staff required additional or refresher training. The registered manager used a dependency tool to assess how many staff were required to safely meet people’s needs. Various audits were analysed to identify busy times of the day which helped to inform staffing levels. For example, call bell response times and accidents and incidents were monitored daily, an increase of staffing had been introduced to address the audit outcomes.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.