Broughton Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager was aware of the need to develop and support the staff team. This included developing and upskilling staff’s confidence and skills in some areas. For example, reviewing and writing care plans.

The registered manager was enthusiastic and passionate about people receiving good care. They spoke positively about the support they received from the provider

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

This was the registered manager’s first CQC assessment. They had worked at the home for five years and worked with the previous registered manager who had been in post for several years. They had taken on the registered manager role in May 2025, they knew the people well and were focused on driving continuous improvement. The registered manager was passionate about the home and was adjusting to their role and responsibilities. They were well supported by the directors and could contact them at any time.

Two of the 3 health and social care professionals who we spoke with and responded to our request; told us they felt Broughton Lodge was well managed. Comments included, “From our perspective, Broughton Lodge appears to be a well-managed service. Staff coordination, communication, and professional engagement suggest effective oversight and leadership.” The other health and social care professional told us it was too soon to comment on the new registered manager’s management skills. However, they did say, “When we are present staff are very kind and good with patients.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There were processes for raising concerns and providing feedback. The provider had clear information in place for people and for staff on how to raise concerns, including clear complaints and whistle blowing policies.

Feedback from people and their relatives was actively sought through surveys, helping the provider to understand people’s experiences and make informed improvements.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

People were supported by a diverse workforce from different cultures and backgrounds. Staff spoken with all felt they were treated fairly and with respect. The registered manager engaged with staff to involve them with the running of the service. They had an open-door policy, regular staff meetings and worked alongside staff so they could speak openly.

Staff meetings were held regularly, with minutes showing that staff were kept informed of changes and developments within the service. Staff felt supported and involved.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At the previous inspection, the provider had been issued with two breaches under Regulations 12 and 17. These had since been addressed and met, reflecting the providers proactive approach to compliance and quality assurance.

A programme of regular quality audits was in place. Where areas for improvement were identified actions were put in place. The provider had a service improvement plan (SIP). The plan listed actions, for example, installing a new dishwasher, dementia signage, and replacing the conservatory roof. The provider and registered manager were actively using the SIP to monitor and track progress, to add new actions as they were identified through audits.

The provider undertakes a monthly visit. During these visits they review the environment, health and safety, engage with staff and people living at the home, and identify areas for improvement. Records of these visits show that actions are followed up and added to the providers service improvement plan.

The provider also has regular remote meetings with the registered manager. The registered manager confirmed they felt well supported by the provider and could contact them at any time. They told us, “I am lucky to have Directors who are supportive and that I can easily approach with any issues. We have two, 1-hour calls scheduled each week and these are kept religiously. The calls are structured so that we can discuss in detail (gave a list of topics).”

The registered manager was working through the homes policies and procedures to ensure they were up to date, reflected current guidance and were meaningful and relevant to the home.

The provider had a ‘mock inspection’ carried out by an external company in July 2024, which had rated the service as good.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager had a clear process for learning from incidents. Accidents and incidents were reviewed to ensure appropriate staff responses and to identify any emerging themes or trends. Following the first day of the assessment, the manager acted promptly on feedback, demonstrating a responsive and reflective leadership style.

The registered manager and provider were motivated and responsive to our findings at the site visits and were acting on key areas of improvement. For example, looking at dementia friendly signage and activity provision at the home.