Bromford Lane Care Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we did not rate this key question. At this assessment the rating is inadequate.

This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of 2 legal regulations in relation to the lack of consistent person- centred care and acting on and dealing with complaints.

This service scored 36 (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 did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People’s care records did not always provide staff with detailed guidance about people’s individual needs. The provider did not consistently involve or work in partnership with people and their relatives to decide how to respond to any relevant changes in people’s needs.

Some people’s care records lacked key information. For example, where people’s needs or wishes had changed, support plans had not been updated to reflect these. This meant staff lacked clear, accurate and up-to-date guidance to meet people’s individualised needs and wishes. Where people’s known choices had been identified, staff failed to consistently consider these. This meant that people did not have their wishes met. Where care plans stated people liked to watch TV, it did not explain what they liked to watch. This was of particular concern for people who lacked the ability to communicate such preferences and remained in their bedrooms.

The care environment still required adaptation to meet the needs of people the provider supported. For example, the environment was not conducive to supporting or promoting the independence of people living with dementia. Signage was poor to help people navigate the service and locate key areas such as lounges and dining rooms. However, menus and meal choices were now of a pictorial nature, although these were not consistently used. Care plans and other documents were not available in formats to meet people’s needs or preferences.

The provider failed to operate a robust system involving people and their relatives consistently and routinely in the updating and development of person-centred care plans. However, relatives told us they received calls from staff about events or changes directly affecting their loved one.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

There was limited support by the provider to integrate people in the community by visiting local shops, cafes or other suitable amenities. Staff told us, at times, they had outside entertainers visit the service. However, visits from local organisations or groups, in which people may have links or interest were limited. The registered manager told us that none of the people living at Bromford Lane Care Centre attended any day centres or other community-based activities.

Although we saw that handovers took place between shifts, we could not be assured that when agency nursing and care staff had been used that they had received a full induction into the service ensuring continuity of care. The management team were unable to provide assurances and evidence this had been carried out. This was of concern as some people’s care plans and risk assessments did not provide staff with clear guidance on how to meet their individual needs or manage risks.

Staff had not received specialist or enhanced training in supporting people with complex dementia, including that related to alcohol and drug misuse, which impacted on their ability to take appropriate action when supporting such people when they became distressed. During our assessment, the provider’s trainer visited the service to start planning enhanced training such as for diabetes management. They told us they would be working with the new management team to ensure staff had the training required and that their competencies were assessed to ascertain their learning.

There was mixed feedback from relatives about how well the service worked with and involved them in people’s care. People and relatives, we spoke with told us they were supported by a consistent staff team and rotas also demonstrated that, overall, there was a stable staff team although, recently, more agency staff were being used.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People’s electronic care records were produced in a single, standardised written format. The registered manager acknowledged this format did not fully consider or reflect people’s individual information and communication needs. In addition, people’s relatives did not currently have access to these care electronic records, and this had not been explored by the provider.

The provider failed to ensure key information about the service and people’s care was made accessible to them meet their individual information and communication needs, such as information translated into other relevant languages, and the use of braille, pictorial versions, large-print or audio formats. Some staff were of the same ethnicity as people using the service which supported effective communication. However, for 1 person, staff were unable to communicate effectively with them verbally. Other methods of communication, such as the use of online translation applications, were not being used by the provider. This meant the person did not receive information to meet their individual needs and this had the potential to cause isolation and frustration to them when unable to express their needs or wishes. This was compounded further as the person lived with dementia.

We found people’s personal information, and that relating to their next of kin, was not always securely stored, to prevent unauthorised people from gaining access to this. We found the names and telephone numbers for people’s next of kin were being stored in the reception area which was accessible by anyone entering the building. We also found records related to some people’s medicines were left in an unlocked lounge area accessible through the reception. The provider failed to recognise the risk of potential unauthorised access to people’s personal and private information.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

The most recent feedback sought by the provider from relatives of people using the service was in July 2025, with feedback being gathered from just 11 relatives. We found some of the concerns raised on these surveys continued to be raised with us during the assessment. For example, relatives continued to tell us that they did not feel involved in decision making, reviewing of care needs and planning of their loved one’s care needs. Surveys were not in a format to meet all people’s preferred communication methods or their abilities. This meant some people were excluded from providing their views and opinions based upon their abilities to partake in meetings or surveys in the format in which they were presented.

We saw that ‘residents meetings’ took place and the most recent such meeting was held on 13 January 2026. However, the planning and conduct of these meetings did not fully reflect an inclusive approach. Whilst the template completed during these meetings included pictorial prompts, there was no evidence how these meetings were conducted in a manner that reflected people’s individual information and communication needs, to fully promote people’s engagement, or that meeting minutes were shared for all people to read and review. However, we saw that people were encouraged to give feedback on areas such as meals, drinks and activities at these meetings, and that most feedback was positive. Following these meetings, the provider analysed feedback received and generated a ‘You said, we did’ action plan which was displayed around the home.

People and relatives we spoke with told us they knew how to raise a complaint and felt overall these would be addressed and appropriate actions taken. However, 2 relatives told us they had raised concerns with the registered manager, and they were not satisfied with the response they received. One relative told us, “I have e-mailed the manager 3 times but have not received any response.” We brought this to the attention of the new management team who told us they would contact the relative immediately to discuss their concerns. We found investigations into some concerns raised about people’s care had taken place, however, not all complaints had been recorded or acted upon. Those which had been investigated were not robust, and lessons learnt had not been widely shared to help reduce the risk of recurrence.

Where needed, some people had an advocate appointed to ensure their voice was heard.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

We found not all people were supported to access healthcare professionals and appointments or emergency healthcare as needed. People had the supported the needed to access, and attend appointments with, dentists, opticians, chiropodists, dieticians and other supporting professionals. However, we found occasions where healthcare advice had not been sought or referrals made when needed. For example, 1 person had been treated in hospital in July 2025 and their hospital discharge letter stated that a referral to the community Speech and Language Therapy (SaLT) team would be required. We found the provider had failed to make or follow up on this referral until we brought this to their attention, which was 7 months later. This meant the person may have not had their individual dietary needs met for this period of time.

There was a GP linked to the service who carried out weekly visits to the service. Prior to the GP visit, the nurse on duty was required to prepare a list of people who they felt needed to be reviewed that week. The GP was reliant on the nursing staff to ensure they referred anyone requiring a check-up or review to prevent any delays in care and treatment. This included updating the GP on anyone whose health or condition had deteriorated and may require referrals to other health professionals.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The provider and registered manager failed to recognise the inequalities people they supported may face. Although some people had advocates to ensure they were not discriminated against, this was not the case for many people who had restricted access to the community and outside areas. People living with dementia or physical disabilities were not actively supported to address and remove barriers ensuring they had equal opportunities to live a full and varied life. People who were unable to communicate their needs were at risk of not receiving the care and support outlined in their care plans. This included people who were cared for in bed, who were particularly vulnerable to being isolated and overlooked. We observed staff were not consistently providing regular, meaningful interactions, which meant these people did not always receive the monitoring, reassurance or engagement they required. This placed people at increased risk of unmet needs, reduced wellbeing and potential neglect.

The provider had failed to fully consider or address inequality in people’s experience or in the outcomes of their care. People were not fully empowered to give their views about their care, including any experiences they may have of discrimination or inequality. This was due, for example, to the provider’s failure to consistently involve them in the assessment and review of their care needs and preferences, and their failure to fully consider people’s individual communication needs. The provider had not taken steps to ensure the care environment reflected the needs of, and did not disadvantage, people living with dementia or physical disabilities. This included a lack of steps taken to make communal areas and the garden more accessible and safer for people to use independently.

Many bedroom doors had no names, symbols or signage to help people identify their own rooms. This lack of visual cues meant people, particularly those living with cognitive impairments, were not always able to orientate themselves to the correct bedroom

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

At the time of the assessment the provider was supporting people on the end-of-life pathway, and there were many people who were at different stages of this journey. Where appropriate we saw that people had been assessed by health professionals and anticipatory medicines were in place for when they were needed.

Whilst some information had been obtained in relation to people’s end of life wishes, these processes were not robust. We found where people had cultural requirements, these had not always been suitably explored and recorded.

Some people living in the service were supported by loved ones and others by advocates. Where people or their relatives were not ready to discuss planning for their future care, this was not always clearly documented and there was no robust system in place to ensure this was revisited at suitable intervals.

Staff had received some training in relation to supporting people along their end-of-life journey. However, the provider’s trainer told us they had been asked to come in to support the nursing team to strengthen their knowledge and skills and assess their competencies. This piece of work had yet to be commenced.