Broadland House Residential Care Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last focused inspection completed in April 2021 we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service continued to be in breach of legal regulation in relation to medicines, staffing and risk management.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive culture of safety and there were instances where safety events had not been used to continually identify and embed good practice. For example, we found multiple instances where people had not received their medicines as prescribed and these had not been consistently reported to management or health professionals. This meant opportunities for improvement had been missed. However, systems were in place to learn from other events as accidents and incidents and the provider completed investigations, and lessons learnt, into the shortfalls we identified as part of this inspection.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Evidence showed that the service mostly worked well with other professionals to ensure people’s safety. Whilst we did find some shortfalls in relation to referring medicines concerns to health professionals, we mostly found that the service appropriately and promptly referred safety concerns to professionals; the professionals we spoke with confirmed this .

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. We saw that systems were in place to ensure this, including staff training, and that staff were able to demonstrate they understood their responsibilities in relation to protecting people from abuse.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive. For example, there were shortfalls in how the service managed risks associated with pressure ulcers. We found people were not being repositioned as assessed as requiring or the risk had not been identified. In addition, we observed a person being assisted to eat and drink in an unsafe position and a delay in staff attending to an emergency call bell. Whilst no one was harmed as a result of these shortfalls, it placed people at risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Whilst the service had systems in place to monitor and maintain risks associated with the environment and equipment, these had failed to identify that the service had been issued with an ‘at risk’ gas warning notice 2 years prior to our inspection. Whilst the service had undertaken some remedial work to address this, the warning notice was still valid at the time of this inspection which placed people at risk of harm . Following our inspection, the provider took action to fully address these concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff and not all had received regular support, supervisions and appraisals. Whilst we saw staff worked hard to meet people’s needs, they did not always work as a team simply due to a lack of staff. We had mixed feedback from people on staffing levels however our observations confirmed there were not enough to ensure people consistently received person-centred care. Furthermore, we had concerns that only 2 staff on shift overnight was not sufficient to ensure people’s safety in the event of an incident such as a fire, particularly given people’s complex physical and cognitive needs. We also observed multiple periods of time where no staff were present in communal areas. Given that most people who used the service were unable to use a call bell, this placed them at risk of harm and/or not receiving care when needed. However, staff told us they felt supported although not all had received regular supervisions and/or appraisals and team meetings were not taking place on a regular basis.

The provider had effective systems in place to assess and manage the risk of infection. This included risk assessments, audits, and policies and procedures. We observed staff to adhere to best infection prevention and control practices and although the environment was tired in places, we found it to be clean. Equipment was also observed to be clean and other good infection prevention and control practices, such as the use of covered pedal-operated bins, were seen to be in place.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst we found no one had come to harm as a result, records showed that people did not consistently receive their medicines as prescribed and that the service had failed to take prompt and appropriate action in response. For a person, despite there being an appropriate protocol in place for their medicines to be given covertly (hidden in food and/or drink), staff had failed to adhere to this or act when the person refused to take their medicines. A lack of staff also meant the administration of medicines was taking too long, and we observed the staff member responsible for administering medicines completing other tasks whilst doing so; this does not adhere to good medicines administration practice guidance. Following our inspection, the provider took action to address these shortfalls.