Broadgate 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 78 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a positive reporting culture; staff understood their responsibility to report and document where an incident or accident had taken place. The Registered Manager ensured they reported concerns promptly to the local authority safeguarding team.

People and their relatives were confident the service supported people safely and were responsive when they raised concerns. One relative told us, “Yes, it is definitely safe. All the staff are lovely. We had a small concern in the past and it was dealt with swiftly and to my satisfaction.”

The service had a robust approach to the continual improvement of care quality. A proactive approach was taken to ensuring learning was taken from events. We saw the management team had implemented reflective practice for the staff team. This was shared during formal staff meetings and in the daily handover meetings.

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.

People and their relatives were involved in planning their care and support needs. One relative told us, “At the beginning we discussed everything.” Another relative told us, “They speak with me about anything that is required.”

The service used a robust pre-admission tool, which allowed them to ensure they could meet peoples identified needs prior to them moving into Broadgate. A staff member told us, “When a person is admitted into the home, we do a full body map, and if we find anything we report this. We ask people about their likes and dislikes. We get to know them. We report any findings to the seniors who add this information to the care plan.”

The service ensured they worked in partnership with external health and social care partners, to achieve the best outcomes for people. Staff knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example, where a person had experienced changes in their cognition and had been referred onto a specialist team for review. One relative told us about the positive support in place at the service, “My family member had ulcers on their legs which were there before they moved in. Since they moved in, they have healed. They now have no ulcers.”

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.

Relatives told us they felt their family members were safe with staff, and any incidents were reported to them promptly and investigated. One relative told us, “I do feel my family member is safe. I see them every day when I visit with my kids, as we live close by to the home. We are very happy.” Another relative told us, “If I had any concerns I would raise them. The staff are very helpful here.”

The Registered Manager ensured they used outcomes from safeguarding investigations to ensure lessons were learned and care quality was improved where any recommendations were made. Staff we spoke with understood the importance of upholding safeguarding standards and ensuring they reported events to the Registered Manager. There was a provider policy on the duty of candour. This policy guided the Registered Manager or nominated individual to tell the person (or, where appropriate their advocate) when something had gone wrong. We reviewed complaints that had been made and saw this policy had been followed.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had received training on how to support people’s individual needs. Some people at the service could become distressed due to their dementia diagnosis. Staff had received training on how to support people when they became upset or anxious. We saw people were supported safely during our time at the service. Staff were timely in their responses towards people to ensure any distress did not escalate. People’s needs were clearly documented in their care plans, which meant staff had clear guidance on a person’s mental, physical, and social needs. Staff knew how to support people to manage risk. For example, where people living with a risk of falls required the support of staff for mobilising or moving from a chair to a bed with the assistance of equipment.

One relative gave positive feedback about the way staff supported their family member to reduce their risk of falls. They told us, “Every time my family member tries to get out of bed an alarm goes off and the staff are there in seconds.” Another relative told us, “My family member is well supported, because of the attentiveness of the carers and the closeness of their room to the lounge upstairs.”

People we spoke with or observed appeared to be satisfied with their equipment provision and safety devices. We observed staff hoisting a number of people in the lounge, into wheelchairs to move them to the dining area. These manual handling procedures were carried out in a calm, efficient manner with kindly interactions between staff and people. One relative told us, “My family member has mobility issues and lives with dementia. Just over a year ago the staff started using a hoist. This is always done diligently and with care.”

People and their relatives told us they were able to communicate their or their family members’ needs, to ensure they received the right type of support. One relative told us, “My family member is fully mobile, but the staff walk along with them to guide, encourage and assist if required.”

We found personal emergency evacuation plans had been regularly reviewed, ensuring they fully considered the unique needs of people. Staff had clear processes in place for how to respond to an emergency and the evacuation processes to follow.

We observed some genuinely person-centred interactions between people and staff which showed the service support good practice in dementia care. People’s communication needs were clearly recorded. This allowed staff to understand people’s needs and wishes to support them to stay safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People showed the inspection team their bedrooms, which we saw had been personalised to their own tastes, with ornaments, photographs and personal items on the walls. People’s bedroom doors were painted different colours; whilst communal bathroom and toilet doors were white, to aid orientation within the building.

People had access to call bells to call for support if needed. Documentation showed the call bell system and linked sensors for falls management were well maintained, to ensure they were effective and reduced the risk of people experiencing harm. People and relatives told us that the call bells in their bedrooms were working and accessible, and staff responded to them promptly.

The provider had a service improvement plan, detailing the ongoing refurbishment works. Where these works had been completed, we found a welcoming, safe environment for people. One relative told us, “It is a very compassionate and caring environment. You can sleep confidently at night knowing that your relative is safe. Although not looking like the ‘Ritz’, it is kept clean and functional. So, I would recommend it, definitely.”

The maintenance team described a clear process for monitoring environmental safety concerns. We saw there had been regular checks to ensure the home was safe in the event of a fire (for example, by carrying out practice drills.) Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like legionella.) The gas heating system was regularly serviced to prevent harm to people.

Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space.

Bedrooms we observed contained furniture which was secured correctly to the wall as required under Health and Safety Executive (HSE) guidance. The Registered Manager and maintenance person had completed a full audit of all bedroom furniture following our assessment visit to ensure this was safe and fit for purpose.

The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment.

Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the HSE.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

People and their relatives gave positive feedback in response to staff numbers, availability, skills, and their caring approach. One relative told us, “When I go, which is afternoons, there are always plenty of staff there.” Another relative told us, ““I’ve never had a problem to find a member of staff, whatever the day, night or weekend.”

People and relatives told us staff were well trained and knew how to meet their family member’s needs. A relative told us, “The staff always call me about everything. The staff are consistent and with very little use of agency staff.” Another relative told us, “The receptionist is helpful and friendly and there are always staff around.”

We saw from our observations and staffing rotas; there were sufficient staff available to safely provide support to people. Staff were deployed effectively around the building, to provide timely support for people. We saw staff were suitably trained to complete their roles. Staff used their training and skills to respond effectively to people’s needs. Once staff were trained, there were clear ongoing processes to assess their competency. If needed, further support and training was then given to improve staff skills. If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance. Staff we spoke with felt confident about the staffing levels, ensuring they could respond to people’s immediate needs. Staff told us they received regular opportunities to meet their line manager on a one-to-one basis for supervision. These meetings offered staff the opportunity to feedback about their experiences and request further guidance and training if needed.

Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us that the home was kept clean. People told us that staff wore personal protective equipment as needed. Staff knew which personal protective equipment they should wear and when. Staff knew how to put on and dispose of this equipment, in a safe way. This protected people from the spread of infection.

Staff had received food hygiene training. They were able to explain what actions they took to reduce the risk of food borne infections. We saw the kitchen was managed in a hygienic way to ensure people were not exposed to the risk of food borne infections. The most recent check from the food standards agency, had rated the service 5, very good, on 7 February 2025.

Some people at the service used equipment (like walking frames, shower chairs or hoists). We saw these pieces of equipment were reviewed in daily walk arounds by the management team, to ensure deep cleaning took place. There were clear processes and policies in place, to ensure people were protected from the spread of an outbreak or infection. If an infection outbreak occurred (for example diarrhoea and vomiting), there were clear processes in place to reduce the risk of this spreading to other people at the service. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People and relatives told us they had no concerns about the safe management of medicines at Broadgate. People and relatives told us their taking of medicines was always supervised, and that staff gave their medicines at regular times, and as their prescription required. One relative told us, “With my family member’s dementia, they will often refuse to take their medication. But the staff persist and find inventive ways for them to take it. They are simply amazing.”

We observed a clinical staff member during the medicines round and they showed confidence and followed best practice guidelines when administering and recording medicines. The clinic room was kept clean, tidy and organised. Staff knew who to report medicine concerns to. For example, if they felt a person’s medicine was no longer effective, they understood where to document this, and which health professionals to contact.

Some people required ‘as needed’ medicine and staff had clear written guidance on how this should be administered. For example, multiple people required pain relieving medicines to be administered ‘as needed.’ We saw the documentation for these medicines clearly explored the reasons why people had required these medicines, and the records reflected this.

One person required their medicines to be administered covertly. Covert medication is when staff administer medicine without the persons’ knowledge or consent; for example, by disguising it in food or drink without the person knowing. We found the relevant mental capacity assessment and decision-making documentation for this was in place.

We found some prescribed creams containing medicine were not stored securely with clear dates of opening recorded on the labels. The Registered Manager responded promptly to ensure these were stored correctly and updated the staff team immediately during the daily handover meeting. Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff completed regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed.