This inspection took place on 17 and 19 October 2018 and was unannounced.

Broome End is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates 37 people, some of whom are living with dementia, in one adapted building. At the time of our inspection there were 27 people using the service.

Following our last inspection on 12 July 2017 the service was given a final rating of 'Requires Improvement'. A breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified because the provider failed to have effective systems in place to ensure people’s medicines were stored and managed safely. Improvements were also needed in relation staffing levels, due to high reliance on agency resulting in people not being supported by staff that understood their needs and a lack of cohesion amongst staff. Limitations on staff time had meant that the care provided was largely task focussed, with little meaningful stimulation or interaction. We also identified that the governance and quality assurance systems were not effective and had not identified failings in the service, found at the inspection.

At this inspection we found significant improvements had been made. A new manager was in post and had registered with the Care Quality Commission (CQC) to manage the service. A registered manager like registered providers, are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Systems had been implemented which were used to continuously assess and monitor the quality of the service. The registered manager and staff had a clear understanding of what was needed to ensure the service continued to develop, and ensure people received high-quality care.

There were sufficient numbers of staff available to meet people’s needs. Recruitment remained an issue for the service largely due to the rural location. However, three new care staff had been recruited, and a small pool of bank and regular agency staff were being used, to provide continuity. Since our last inspection a deputy manager had been recruited. Where previously the registered manager had been overseeing all aspects of the service, the additional resources had freed up their time to focus more on their managerial duties.

This service was selected to be part of our national review, looking at the quality of oral health care support for people living in care homes. The inspection team included a dental inspector who looked in detail at how well the service supported people with their oral health. This includes support with oral hygiene and access to dentists. We will publish our national report of our findings and recommendations in 2019. However, for this inspection we found oral health training for staff was basic. The deputy manager had taken on the role of oral health champion and outlined plans to improve oral health care, including training. Champions are staff that have shown a specific interest in specific areas. They are essential in developing best practice, by sharing their leaning and acting as role models for other staff.

Staff felt supported by the management team, in particular the registered manager. Staff were encouraged to further their knowledge and skills through a combination of training methods, including eLearning as well as external trainers coming to the service. Staff’s competencies had been assessed to ensure they had understood what they had learnt and were able to effectively apply it to their daily practice.

People were protected from risk of harm and staff had a good understanding of processes to keep people safe and how to report concerns. Safeguarding incidents were managed well.

We carried out an unannounced inspection of Broome End on 12 July 2017. Broome End is registered to provide personal care and accommodation for up to 37 older people, some of whom are living with dementia. The service is spread out across three floors with communal lounge and dining areas located on the ground floor. The service has an extensive secure garden area which people are able to access if they choose. When we visited there were 27 people living at the service.

We last inspected the service on 26 April 2016 and rated the service as requires improvement. This was because we had some concerns around low staffing levels, especially at night, and the lack of support given to the registered manager. During this inspection we found that although some improvements had been made to the management structure of the service we continued to have concerns about low staffing levels at night and a high reliance upon agency staff resulting in a lack of cohesion amongst staff.

At the time of the inspection there was not a registered manager in post. Since the previous inspection a new home manager and deputy manager had been appointed. The new manager was in the process of registering with the commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’, Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Whilst care plans were person centred and detailed in places some lacked specific information about people’s care. This meant that they did not consistently reflect the needs of people and at times staff lacked guidance on how to minimise potential risks.

A high reliance upon agency staff meant that people could not be assured that they were being supported by staff who knew them well. Consequently, people did not always receive care and support that was suited to their individual needs and preferences. Staff were not always deployed effectively to meet people's needs and at meal times there were not enough staff available to support people to eat and drink in a dignified manner.

Effective systems were not in place to ensure that medicines were consistently stored and managed safely.

Staff had completed a variety of training modules. However, they were largely provided through on line sessions and there was no evidence to show that following the training staff had their competencies assessed to ensure that they had understood what they had learnt and were able to effectively apply it to their daily practice.

Whilst staff were caring in their approach limitations on their time meant that the care provided was largely task focussed. Some people participated in a variety of activities however, people with a greater need were left for periods of time with little meaningful stimulation or interaction.

Whilst systems were in place to monitor the quality and safety of the service records showed that they had not always been used effectively. This meant that the management team did not have a clear oversight of the service.

Staff understood how to recognise signs of abuse and were confident in the action that they would take to raise any concerns.

The service had a recruitment process in place to ensure that staff were safe to work with people living at the service.

Staff worked in line with the principles of the mental capacity act and understood their responsibilities to ensure people were given choices about how they wished to live their lives.

The manager and deputy manager were a visible presence around the service and supportive and accessible to staff. Together they had worked hard to develop effective working relationships with local healthcare professionals.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the

The inspection took place on 28 April 2016 and was unannounced.

The service provides accommodation for up to 37 older people some of whom may be living with dementia. At the time of our inspection 26 people were living at the service. We last inspected the service on 16 July 2015 in response to concerns that had been raised with us. At that inspection we rated the service Requires Improvement but did not carry out a fully comprehensive inspection. This inspection was carried out to check on the improvements we required and look at areas of the service not previously checked.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff were trained in keeping people safe from abuse and understood their responsibilities should they suspect abuse had occurred. Staff were able to outline how they would report any concerns they had.

Risks to people’s health and wellbeing were assessed and reduced as much as possible.

Staffing levels were sometimes low, especially at night, and did not always reach the level the service had assessed as safe.

Medicines were well managed and regularly audited.

Staff received a structured induction and training was provided to equip them to carry out their roles. Experienced staff demonstrated a good knowledge of the people they were supporting and caring for and knew people’s particular preferences and wishes with regard to their care.

We saw that staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Staff demonstrated a basic understanding of the principles of the MCA and DoLS.

People who used the service were very positive about the food and were able to exercise choice about their meals. Mealtimes were sociable occasions which people greatly enjoyed. People identified as being at risk of not eating enough were referred to appropriate healthcare professionals and monitored.

People were supported to access healthcare professionals when they needed them and the staff involved relevant professionals when a person’s health declined. The GP expressed concerns that sometimes the service did not alert them promptly enough when someone became unwell and sometimes information about people’s health was not accurate. The district nursing team also had concerns and there was a poor relationship between them and the manager of the service which had the potential to place people at risk.

Staff were caring and committed and we saw that people were treated respectfully and their dignity was maintained. The atmosphere was of a friendly place and the good relationships between staff, the people they were supporting and visiting relatives were observed throughout the service. Relatives were very positive about the caring nature of the staff.

People, or their relatives, were involved in assessing and planning their care and plans were regularly reviewed.

People were supported to follow different interests and hobbies and to go out on trips. People living with dementia and those who did not wish to take part in structured activities were provided with one to one sessions.

There had been no formal complaints but informal complaints were logged and investigated in line with the provider’s complaints procedure, and to people’s satisfaction.

The service had an open cultur

The inspection took place on the 16 July 2015 and was unannounced. This service was inspected because of a number of concerns we received about the service. We visited to ensure that the needs of the people using the service were being met and people were safe. The report focuses on the concerns and not all the key lines of enquiry we inspect against were looked at in much detail. We have given the service a rating but will choose to re-inspect the service again to check out the rating.

The service was last inspected on the 07 April 2014 and was meeting all the required standards of care.

The service is registered for Accommodation for persons who require nursing or personal care and can accommodate up to 37 people. The service had a registered manager in post at the time of our inspection.

‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

During this inspection we identified some risks to people’s health and safety including safety certificates which had lapsed in relation to legionnaires testing. This has since been addressed.

Most people were supported to eat and drink enough for their needs but some people needed additional monitoring and encouragement to ensure this happened. Records did not always reflect the fact that people are adequately supported in terms of their health needs.

During this inspection we found there to be enough staff to meet people’s needs. However this fluctuated according to levels of staff sickness and the ability to get agency cover. Staff recruitment was on-going.

Staff knew how to raise concerns and had received training in protecting adults.

There were systems in place to ensure people received their medicines safely and staff that were competence to give medicines.

Staff were effectively supported and received the training they required for their job role so they had the necessary skills. There were adequate recruitment processes in place.

People were supported to make appropriate decisions about their health and welfare.

Some poor practices were observed around lunch time in the small dining room where people's independence and dignity were not upheld. The dining experience in the main dining room was observed as caring and pleasant.

People were involved in their care and asked to contribute to decisions about their care and welfare.

People were given opportunities to partake in a range of activities around their individual interests and hobbies, including trips to the local community.

People’s needs were assessed and records were comprehensive and mostly up to date. They gave us a good insight into people’s needs and how they were being met. We identified some minor gaps in terms of records and not always being up to date when people’s needs had changed.

We did not look at complaints but saw there was an established complaints procedure.

The service had continuity of management and audits took place to assess the safety and suitability of the service being provided.

We considered our inspection findings to answer the five questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service caring?

We spoke with three people who used the service. We were not able to speak with some of the other people due to their communication needs. One person said to us, "The staff are lovely here; they look after me well." Another person said, "I feel safe here." We observed the care and attention people received from staff. All interactions we saw were appropriate, respectful and friendly.

Is the service responsive?

We saw that care plans and risk assessments were informative, up to date and regularly reviewed. The provider used an outside company to assist them with monthly monitoring visits and responded appropriately to action plans set and suggestions made. The manager responded in an open, thorough and timely manner to complaints. Therefore people could be assured that complaints were investigated and action was taken as necessary.

Is the service safe?

The accommodation was adapted to meet the needs of the people living there, was suited to caring for people with limited mobility and was properly maintained. The home was warm and clean and was personalised to the people who lived there. People were protected by robust staff recruitment systems. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines.

Is the service effective?

People we spoke with were satisfied with the care and support they received. No one raised any concerns with us. This was consistent with generally positive feedback from people reported in the provider's own annual quality assurance survey.

Is the service well led?

Staff said that they felt well supported and were able do their jobs safely. The provider had a range of quality monitoring systems in place to ensure that care was being delivered appropriately by staff, that the service was continuously improving and that people were satisfied with the service they were receiving.

During our inspection of Broome End on 19 August 2013, we spoke with nine people who lived there, four of their relatives, four members of care staff, the manager and the provider.

Some people who used the service at Broome End were not able to tell us about their experiences so we used a number of different methods to help us understand. We observed the interactions between people who used the service and the staff working at the home and we listened to everyday events and activities during the course of the day. We saw that people who used the service initiated interactions, approached staff with confidence and were responded to in a warm and respectful way.

We spoke with four relatives during our visit to the service on 19 August 2013 and after that visit, we spoke on the telephone with two other relatives who frequently visited the service. They all told us that they felt that people were provided with good care and had support for social and leisure activities.

Broome End had undergone considerable refurbishment over the past six months since the home had changed ownership. The first and second floor programme had been completed. The provider told us that the entire refurbishment programme was planned to be finished, including a ground floor lounge extension, by March 2014.