Broadoak Manor Care Home

The provider was in breach of 6 of the legal regulations relating to person-centred care, dignity and respect, consent, safe care and treatment including medicines management, safeguarding and good governance.

Lessons were not always learnt to continually identify and embed good practice. Systems in place to review accidents, incidents and trends were not effective in identifying some of the concerns and inconsistencies we found. People were not always protected from abuse and improper treatment; the provider failed to ensure the use of restrictive practices were legally authorised, risk assessed and reviewed in line with the requirements of the Mental Capacity Act 2005.

People were not always provided with safe care and treatment; they were not protected from the risk of choking. We found shortfalls in Infection Prevention and Control (IPC) systems; the provider failed to ensure the environment was clean. Medicines were not managed safely, and we were not assured all staff had received appropriate training to meet the needs of people.

People were not always treated as individuals, with dignity and respect, or provided with person centred care. There was a lack of activities and stimulation for people living in the home.

Improvements were required to ensure care plans were person centred and reflective of people’s preferences and specific assessed needs.

Governance systems were ineffective in assessing, monitoring and driving improvement. There was a lack of provider oversight of key areas of risk within the service.

The service had recently undergone changes in management, with an interim manager in place at the time of the assessment. Staff provided positive feedback about these changes and told us they felt able to raise concerns with the management team.

We observed some positive interactions between staff and people, and it was evident some staff knew people well and had built good rapports.

Following the feedback, the management team developed a new action plan to work towards and had already began making some changes within the service.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

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.