Broadoak Manor Care Home

Updated 29 December 2025

Date of Assessment: 6 January to 3 February 2026. Broadoak Manor Care Home is a residential care home providing nursing and personal care for up to 120 people across 4 separate units. At the time of our assessment, 105 people were living at the home, some of whom were living with dementia. We carried out this assessment due to an increase in safeguarding concerns received by CQC, indicating people were not receiving safe care or treatment.

The provider was in breach of 6 of the legal regulations relating to person-centred care, dignity and respect, consent, safe care and treatment including medicines management, safeguarding and good governance.

Lessons were not always learnt to continually identify and embed good practice. Systems in place to review accidents, incidents and trends were not effective in identifying some of the concerns and inconsistencies we found. People were not always protected from abuse and improper treatment; the provider failed to ensure the use of restrictive practices were legally authorised, risk assessed and reviewed in line with the requirements of the Mental Capacity Act 2005.

People were not always provided with safe care and treatment; they were not protected from the risk of choking. We found shortfalls in Infection Prevention and Control (IPC) systems; the provider failed to ensure the environment was clean. Medicines were not managed safely, and we were not assured all staff had received appropriate training to meet the needs of people.

People were not always treated as individuals, with dignity and respect, or provided with person centred care. There was a lack of activities and stimulation for people living in the home.

Improvements were required to ensure care plans were person centred and reflective of people’s preferences and specific assessed needs.

Governance systems were ineffective in assessing, monitoring and driving improvement. There was a lack of provider oversight of key areas of risk within the service.

The service had recently undergone changes in management, with an interim manager in place at the time of the assessment. Staff provided positive feedback about these changes and told us they felt able to raise concerns with the management team.

We observed some positive interactions between staff and people, and it was evident some staff knew people well and had built good rapports.

Following the feedback, the management team developed a new action plan to work towards and had already began making some changes within the service.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Updated 29 December 2025

Most people and family members gave positive feedback about the staff. Comments included, “The staff are good,” “The staff are very kind to me” and “They speak to mum nicely.”

Family members told us they were kept up to date with any changes and were able to visit any time without restrictions. People felt safe living at the home. One person told us, “I feel safe here” and “Staff look after me.”

We observed some activities taking place; however, these were limited and not always in line with people’s preferences. One person told us, “It can be a bit boring here but it’s okay,” whilst another told us, “We play games sometimes, like Dominoes but there’s not much else.”

Some people raised concerns regarding staffing levels, and the time staff took to respond to them. One person commented, “If I press my buzzer sometimes it takes a while for them to come.” We observed instances on some units whereby we had to alert staff members to support people with nutritional and hydration needs.

We observed some positive interactions between staff members and people throughout the site visits.

Whilst people and families expressed general satisfaction with their care and treatment, our assessment found the quality of the care and support did not meet the expected standards.