CQC report explained · a nursing home, run by Welltower

Broadway Halls Care Home

The Broadway, Dudley, DY1 3EA

Requires improvementpublished 29 February 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask

Safe?: Requires improvement; Medicines were not always managed safely. Inspectors also found that risks linked to pressure sores, thickening powder and recruitment records needed improvement.
Effective?: Good; People's needs were assessed and care plans were in place. Staff worked with health professionals and supported people to make choices and give consent.
Caring?: Good; This key question was not inspected during this focused inspection.
Responsive?: Good; This key question was not inspected during this focused inspection.
Well-led?: Requires improvement; The home's quality checks did not always identify or resolve problems, including medicines issues and low fluid intake. The manager had an action plan and was working with commissioners.

The latest report, explained

What inspectors found, February 2024

Rated Requires Improvement; inspectors found concerns about medicines, pressure sore prevention, staffing and checks on the quality of care.

This was an unannounced focused inspection on 8 and 9 September 2022. Inspectors spoke with people, relatives and staff. They reviewed care records, medicines records, recruitment files and management records.

The home was not always safe. Medicines records had unexplained gaps, some storage checks were missing, and risks linked to pressure sores were not always managed consistently. Recruitment checks also needed improvement.

The home was rated Good for Effective. People received support from health professionals, staff sought consent and care was planned around people's needs. However, the home was rated Requires Improvement for Safe and Well-led because its checks did not always identify or fix problems.

The previous overall rating was Good, published in May 2019. This inspection did not assess Caring or Responsive, so those areas were not given new ratings.

What inspectors praised

People felt safe
People and relatives said they felt safe. Staff knew how to recognise and report possible abuse.
“People felt safe living at the home, and their relatives were confident in their loved ones' safety.” from the report
Support from other services
Staff worked with health and social care professionals. Records showed involvement from several outside services.
“Staff worked with other agencies to ensure people received a joined-up approach to their care.” from the report
Consent and choice
Staff asked for consent and offered choices. Care plans recorded relevant legal authorisations.
“We observed staff offering people choices and gaining their consent before carrying out tasks.” from the report
Open communication
Relatives said they were informed when things went wrong. Staff described the management team as approachable and supportive.
“Relatives told us they were informed when things went wrong.” from the report
Action plan
The manager had an action plan covering responsibilities, deadlines and progress, and was working with commissioners.
“This action plan outlined who was responsible for completing each action, the target completion date and progress made to date.” from the report

What inspectors were concerned about

Medicines records and storage
serious
There were unexplained gaps in medicines administration records and stock balances were not always accurate. Medicine fridge temperatures were also not consistently recorded.
“Several people's medicines administration records (MAR) contained unexplained gaps in recording.” from the report
Pressure sore prevention
serious
At least one person needed regular repositioning, but support to reduce the risk of pressure sores was not always consistent.
“People had not always received consistent support to reduce their risk of pressure sores.” from the report
Staffing and recruitment
needs fixing
People, relatives and staff raised concerns about staffing levels. Employment gaps for five staff had not been explored.
“We found gaps in the employment histories of five members of staff had not been explored with them.” from the report
Management checks
serious
The home's audits did not always identify or act on important problems, including medicines concerns and low fluid intake.
“The provider's quality assurance systems and processes were not effective and had not enabled them to assess, monitor and improve the quality and safety of the service.” from the report
Food and drinks
minor
People gave negative feedback about the food. When fluid targets were missed, records did not always show what action had been taken.
“People provided negative feedback about the food.” from the report

Questions to ask them, based on this report

01What action has been taken to stop unexplained gaps in medicines administration records?
02How are medicine fridge temperatures and PEG feed storage temperatures now checked and recorded?
03How do you make sure people at risk of pressure sores are repositioned consistently?
04What has changed in staffing levels since the inspection, especially at night and on the nursing floor?
05How do your current audits identify and act on missed fluid targets and other care risks?

This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over when the overall rating was calculated. This explanation was written from the published report of 29 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Broadway Halls Care Home

4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.

February 2024Requires improvementcurrent rating
Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Broadway Halls Care Home →
February 2022Inspected but not rated
Safe: Inspected but not rated
We are reading this report · the original is on cqc.org.uk
May 2019Goodstayed Good
Safe: GoodEffective: GoodWell-led: Good
Read this report on cqc.org.uk
November 2016Goodup from Requires improvement
Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read this report on cqc.org.uk
September 2015Requires improvement
Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read this report on cqc.org.uk
September 2014Inspected but not rated
Read this report on cqc.org.uk
September 2013
Report published without a new overall rating.
Read this report on cqc.org.uk
February 2013
Report published without a new overall rating.
Read this report on cqc.org.uk
December 2012
Report published without a new overall rating.
Read this report on cqc.org.uk
October 2011
Report published without a new overall rating.
Read this report on cqc.org.uk
November 2010
Registered with the Care Quality Commission on 30 November 2010.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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