Broadoak Grange

This assessment was carried out due to the length of time since the last inspection.

The provider was in breach of 4 legal regulations related to consent to care and treatment, safe care and treatment, safeguarding, and good governance.

People were supported by kind and caring staff who understood their individual needs and worked effectively with healthcare professionals to promote joined-up care. Staff treated people with dignity and respect and sought to support people to make decisions about their care wherever possible.

However, the provider did not always ensure risks to people were adequately assessed, understood or managed. Care plans and risk assessments lacked sufficient guidance for staff and were not always accurate, person-centred or reflective of people's current needs. Records were not consistently complete, contemporaneous or aligned with the care provided. Medicines were not always managed safely, and staff did not always have the information, training or competency assessments required to safely carry out delegated healthcare tasks and medicine-related responsibilities.

The provider was not meeting the requirements of the Mental Capacity Act 2005. Mental capacity assessments and associated decision-making processes were not always completed in accordance with MCA principles, records did not consistently demonstrate decision-specific assessments, and people were not always supported through a lawful and robust decision-making process. Oversight of Deprivation of Liberty Safeguards was also ineffective.

Environmental and infection prevention and control risks had not always been effectively managed. Recruitment processes were not sufficiently robust to ensure all staff were suitable for their roles, and systems for ensuring staff received appropriate training were not consistently effective.

Governance, auditing and quality assurance systems were ineffective and had failed to identify and address the widespread concerns found during the inspection. These included issues relating to care planning, risk management, medicines management, MCA and DoLS, recruitment, infection prevention and control, staffing oversight and record keeping. Although the management team responded positively to inspection feedback and had begun implementing improvements, further work was required to ensure people consistently received safe, effective and well-led care.

We have asked the provider for an action plan in response to concerns found at this assessment in relation to consent to care and treatment, and safeguarding.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.