Broughton Lodge

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 – 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 69 (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 registered manager demonstrated a strong commitment to creating a culture of learning and continuous improvement. They had a clear focus on ensuring the wellbeing of people at the home. As a new registered manager, they were working closely with the provider and the local authority quality team, implementing a service improvement plan to address identified areas of concern.

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 were supported to attend healthcare appointments and access GP services when needed. The registered manager explained that concerns about people’s health were raised through an online portal system. These alerts were reviewed and triaged by a multi-disciplinary team, enabling appropriate action to be taken to support people’s health and wellbeing.

Feedback from health and social care professionals was mostly positive. However, some healthcare professionals highlighted concerns regarding the timeliness of reporting a concern. We discussed this with the registered manager, who was aware of the incident and assured us no harm had been caused.

When people required hospital admission, staff ensured that hospital passports were sent with them.These passports contained key information about the individual’s health, communication needs and preferences. This enabled hospital staff to provide safe, person-centred care and support, tailored to the people’s needs.

Where people needed additional support, staff worked with health care professionals to help manage their needs. For example, 1 person was experiencing mental health difficulties, staff were working with the older people’s mental health team regarding helping them.

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.

People who could express themselves told us they felt safe living at the home. Staff confirmed they knew how to raise concerns about abuse or incidents and were confident that the registered manager would act appropriately.

Staff had received appropriate training in safeguarding adults, in line with current legislation and best practice guidance. The provider’s safeguarding policy and procedures were available for staff. This meant staff, ensured that people using the service were protected from the risk of abuse and neglect.

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.

Individual risks of harm were assessed and managed through care records, and staff demonstrated a good understanding of the people they supported, helping to mitigate risks effectively.

Personal Emergency Evacuation Plans (PEEPs) were in place for individuals requiring assistance during an emergency and were regularly reviewed and updated to ensure they remained accurate and effective.

The Food Standards Agency undertook an inspection in March 2025, and awarded the home a 5-star rating, reflecting very good standards in food hygiene and safety.

The provider had a comprehensive fire risk assessment completed in accordance with regulatory requirements. The assessment had identified a few recommendations, which the provider was working through. Fire alarms are tested weekly to ensure functionality and compliance with safety regulations.

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

Environmental safety was maintained through routine checks, and staff were able to identify and record concerns. The home had been redecorated throughout, creating a pleasant and well-maintained environment.

The provider informed us that they had undertaken unexpected maintenance work at the home in 2025. This included the replacement of approximately half of the roof and an upgrade to the fixed electrical installation to ensure continued safety and compliance.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff had received effective support, supervision and development and worked together well to provide safe care that met people’s individual needs.

The provider used a dependency tool (a system for assessing people’s needs and the required numbers of staff to meet them) to assess staffing levels required. We discussed with the registered manager, that time allocations needed to be reviewed for people requiring 2 staff and required hoist support, to ensure they were allocating enough staff to meet people’s needs.

Staff told us generally there were enough staff to support people and respond to their needs in a timely manner. However, we saw, and staff confirmed they were kept very busy and didn’t always have time to provide activities.

People gave us a mixed views about the staff levels. Comments included, “I’m bored, there are no church services”, “I quite like it here, there always seem to be enough staff around” and “I ring the bell to ask for help going to the toilet, it takes them 10 to 15 minutes to come.”

Each day a team leader and 2 care staff were allocated on duty to provide personal care to people. These staff were also required to provide activity provision, which did not always happen as staff were busy supporting people. No agency staff were used at the home. Staffing levels were maintained through existing staff picking up additional shifts, and the registered manager also covered shifts when needed.

Staff received training relevant to their roles. The registered manager was actively working to ensure new staff completed the providers mandatory training. They told us, “Under my guidance we are all trying to accomplish high levels of training, which I believe to be crucial to running a smooth operation as well as giving the team a real sense of professional achievement and pride.”

On the first day of our visit, 2 new staff had not received manual handling training. This was rectified by the second day.

Recruitment processes were robust, with a checklist in place to ensure all necessary documentation, including previous employment references and a Disclosure and Barring Service check (DBS), were obtained. The registered manager signed off recruitment forms to confirm staff were safe to work alone. Action was taken after our first visit to ensure a negative reference which we had reviewed was formally reviewed and action recorded.

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.

Cleaning tasks were completed by housekeeping and night staff using a checklist, and the home was clean throughout.

Staff had received training in infection prevention control. Personal Protective Equipment (PPE) was available and appropriately used across the home.

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.

Medicines were generally managed safely. People received their medicines safely from staff who had received specific training and had their competency assessed to administer medicines.

However, during this assessment we found the medicine room temperatures were not recorded consistently. The registered manager addressed this immediately and put in place regular controlled medicines checks. Regular audits of medicines were completed and where actions were identified these were acted upon. PRN (as required medicines) protocols were in place and 1 was updated during the assessment.

Staff were observed administering medicines in line with best practice. They wore red "do not disturb" tabards to minimise interruptions and maintain focus during the medicine round. Staff engaged with people respectfully, asking whether they required any pain relief and remained with them to ensure medicines were taken safely and comfortably.