Broadacres Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found a breach of legal regulations in relation to good governance and the provider had not ensured appropriate systems and processes were in place to fully assess, monitor and improve the quality and safety of the service provided. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our previous inspection of the service in 2022 there had also been a breach of regulation 17 and no improvement was seen during this inspection and assessment. Systems had not been effective in identifying some concerns we found during this assessment. At the time of our inspection there was no registered manager in post and the home had been without a registered manager since January 2022. The absence of a stable management team had created a lack of leadership in the service. Where issues had been identified they were not always resolved in a timely manner. The provider had started addressing these concerns and implementing systems to support staff, however, these required embedding in to practice.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told is there have been a lot of change in relation to management, "There's been a lot of management changes but this one seems ok." Conversations with staff indicated they did not feel involved in the shared vision for the home.

The culture within the home was not one of diversity and inclusion. There were limited dementia friendly resources. There was a train carriage room with an interactive screen but we did not see this in use during our site visits despite a person being sat in this room. Staff told us the person liked a quiet area so they used this room. There was no evidence of the management team leading, guiding or directing staff. The activity co-ordinator spent most of their time on one unit. The local authority identified that people living on the other unit were not receiving social stimulation. The arrangement for activities then changed without any consultation with people.

At the time of our inspection the home had been without a registered manager since January 2022. There was no stable management team in place and this had created lack of leadership. Systems had not been effective in identifying some concerns we found during this inspection. Where issues had been identified they were not always resolved in a timely manner. The provider had started addressing these concerns and implementing systems to support staff, however, these required embedding in to practice.

The manager of the service did not feel supported in their post by their manager. A new deputy manager had been recruited recently which provided additional support for the manager. There was a feeling that there was a lack of consistency in the home with no clear path to follow and poor guidance. Following the first day of inspection, an interim manager provided cover and support for the staff team in the home. Staff were more positive about the support they received and the processes that were being put into place.

Staff were aware of the whistle blowing procedures and told us they would use the process if they needed to.

There was a freedom to speak up guardian in place so staff could get support around whistle-blowing. Staff were aware of the policies and procedures around speaking up and how to access support. Resident and relative meetings took place and we saw evidence of actions taken to address issues raised in the meetings.

There were a range of staff and team meetings where key updates were provided and key themes discussed. These include health and safety and governance where service audits and assessments were discussed.

There were a range of policies and procedures in place that supported the fair and equitable treatment of staff who worked in the service. These included workforce well-being, diversity, gender pay gap and flexible working arrangements.

Staff made us aware that there were issues with the management of the home. This was echoed by feedback from the local authority about their quality assessment of the service.

There were a range of audits and reviews carried out by the management team. We reviewed these audits and found that they were not always effective. Issues identified around cleanliness of the home had been identified and signed off as complete in an audit of housekeeping services but found those same issues were still present when we inspected the service. This showed that the audits and review process were not effective in addressing identified concerns.

People told us they accessed health and care services from the local community. GPs and nurses visited people if they needed clinical interventions and support. Although people responded positively we were not assured the service had effective systems and processes in place to ensure community engagement and access to community services were embedded in to practice.

Staff did not tell us about how they supported people to access local services in the community. Visiting professionals did tell us that appropriate referrals for intervention and support were made by staff.

A recent local authority contract quality assessment rated the service as poor. Facilitation and promotion of community engagement required embedding in to practice. This had been impacted by the changes in the management team and the lack of stable management and leadership.

Systems had not been effective in identifying some concerns we found during this assessment. Where issues had been identified they were not always resolved in a timely manner. The provider had started addressing these concerns and implementing systems to support staff, however, these required embedding in to practice.

Conversations with staff confirmed they were aware of how to speak up about any concerns and where to go if they needed more support. The service supported student placements to promote learning and development of people on health and social care courses. Although staff responded positively and did not raise any concerns in respect of learning, improvement and innovation, we were not assured about how the lessons learned and improvements in practice were cascaded and shared with staff.

Analysis of events took place to identify lessons learned but it was unclear from reports how the lessons learned were cascaded with staff and how improvements in practice were implemented, monitored and reviewed.