Broadoak Manor 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 – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding, and the way people’s medicines were managed safely.

This service scored 38 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Accidents and incident records for some people showed a repetitive cycle of incidents, suggesting actions taken following incidents had not been effective in preventing recurrence or reducing risk.

Monthly home learning meetings were in place and were used to analyse events for each monthly period, such as the number of incidents and when they occurred. However, there was no evidence of detailed analysis of individual incidents. Records did not show learning from accident and incidents, or evidence recommended best practice was routinely shared with the full staff team during staff meetings.

The interim manager had started to carry out investigations into incidents where appropriate in relation to more recent incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

For example, we found instances when the provider had not accurately reviewed and aligned information about a person provided by the hospital on discharge. This put people at risk of their health deteriorating and not receiving their correct medication.

The service included a step-down unit from hospital, often used for short term placements for people. The provider had developed a screening and preadmission assessment tool to support transfers for this type of admission from hospital to Broadoak Manor Care Home.

The provider did not ensure people were protected from abuse and improper treatment at all times. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider failed to ensure all use of control, restraint or restrictive practices was legally authorised, risk assessed and reviewed in line with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

We found instances when restrictive interventions were used without legal authorisation. For example, staff used physical restraint with one person to stop them hitting, but there was no authorisation permitting the use of restraint for this person. The management team did not have any oversight of this incident, as it was not recorded in the provider’s restraint incident log.

Furthermore, we found several incidents where physical restraints were used outside the legal scope of authorised restrictions. For example, one person’s mental capacity assessment, best interest decision and DoLS authorisation permitted the use of arm holds as a last resort. However, staff had used alternative techniques, including leg holds, which were not authorised.

Risk assessment and care plans relating to the use of restrictive practices were not always in place, up to date or contained conflicting information. This increased the risk of staff using disproportionate restraint and placed people at risk of harm and unlawful restriction.

We were not assured by the knowledge and response from the management team in relation to the concerns we raised regarding the use of restrictive practices. CQC raised a safeguarding referral with the local authority.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were not always protected from the risks of choking. We found conflicting and incorrect information about peoples assessed dietary needs across all the units, within care plans and in the main kitchen. Further discrepancies in the recording of people’s food charts provided us with no assurances people were always getting the correct texture of food for their assessed needs.

For example, one person was assessed as requiring a Level 6 soft and bite-sized diet. However, this was not recorded in the main kitchen or on the unit where they lived. Their food chart recorded they had received a Level 7 normal diet on the 2 entries that had been recorded in December 2025. We were not assured this person had received a diet suitable for their assessed needs. They were put at risk of avoidable harm.

Following our feedback, the provider completed a full audit of dietary needs across the home. This audit identified conflicting and missing information, consistent with our findings.

The provider did not always make sure equipment supported the delivery of safe care. For example, we identified commodes throughout the home were dirty and in poor condition.

We observed some bedrooms were left unlocked and used to store equipment. People had unsupervised access to these areas, which increased the risk of avoidable harm.

Following our feedback, the provider completed a full audit of commodes and ordered replacements where required.

Safety certificates, such as gas and electrical certificates, were in place and up to date.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Records showed staff did not receive regular supervision or appraisal. Some staff had not received supervision for nearly a year. Lack of supervision meant managers were unable to monitor staff performance or provide appropriate support when needed.

We were not assured all staff had received specialist training to meet the needs of people, or their competencies had been assessed. This included training in catheter care, stoma care and medication administration. One person told us, “There was a carer yesterday who didn’t know how to empty my commode, so I had to talk him through it.” One staff member told us they supported with stoma care but had not received any training in this area.

However, we found staff were recruited safely. All relevant documents and checks were completed before staff began employment.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified infection prevention and control (IPC) concerns across all units. We observed dirty bedding, pillows and toothbrushes in people’s bedrooms, and there was a strong smell of urine in some areas of the home. Equipment and commodes were visible dirty, as were some slings and chairs in communal areas. Staff disposed of PPE incorrectly; for example, we found used gloves in general waste bins in people’s bedrooms alongside used continence products.

There were gaps in cleaning schedules, as domestic staff did not consistently record when they had completed tasks. As a result, we could not be assured cleaning was being completed, in line with the provider’s requirements.

Following our feedback on day 1, we observed some improvements in cleanliness on day 2. The provider introduced a new cleaning schedule with increased oversight, and additional IPC training was provided to staff.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Records provided showed staff had not always completed training related to medicines as appropriate.

Medicines were stored securely, however, when staff monitored the temperature of fridges used to store medicines they did not always document any action taken when it was outside of the recommended range.

People did not always receive their medicines as prescribed as the provider did not always have the medicines required in stock. This included critical medicines such as pain relief. We saw no evidence of gaps in electronic medication administration records (eMAR); however, medicines stock balances did not always accurately reflect the number of medicines in stock.

Staff did not always document the correct level drinks had been thickened to for people at risk of choking. We could not be assured people had their drinks thickened in line with the prescriber’s instructions.

Staff ensured people had access to medicines when they were away from the service, for example, when visiting family, however, it was not clear if staff had followed the providers policies to ensure this was being done in a safe way as there were no risk assessments available and no information in care plans to instruct staff on how to make medicines available safely.

Instructions for medicines that were given when required (PRN) were available, however, they did not always contain person-centred information. Staff did not always document the outcome for people when these medicines had been given, so it was not clear if they had been effective or not.

Information provided by the hospital for 1 person on discharge had not been reconciled correctly by the provider. This meant changes made to a person’s medicines when they were discharged from hospital were not correctly added to the record at the home. For example, the person’s allergy status was not recorded and an inhaler prescribed on discharge from hospital had not been recorded on the eMAR so the person did not receive this medicine. This put the person at risk of receiving a medicine they were allergic to and a worsening of their condition from not receiving the correct medication.

The eMAR system recorded the time of administration of medicines, however, records did not always reflect staff followed instructions related to these medicines. For example, we saw evidence of paracetamol being given without leaving the recommended 4-hour gap between doses and for one person prescribed a patch which needed to be removed after 12 hours this instruction was not always followed and there were occasions where this had been left applied over 14 hours.

Medication administration records for topical preparations such as creams were completed.