Broadoak Manor Care Home

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 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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to governance at the service.

This service scored 39 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We received mixed feedback about the culture of the home, particularly on some units. Some staff members described a negative culture on certain units where cliques between staff members had formed. Staff told us this sometimes affected how situations were managed, how people were spoken with and how information was escalated.

We found the provider did not always respect people’s human rights in respect of the MCA and DoLS.

The service was going through a period of change, with recruitment underway for a new registered manager. The interim manager had been in post since October 2025.

Staff gave positive feedback about the interim manager and area director, and the support they were receiving. During our visits, leaders were visible and supported the assessment process. They were open, honest and responsive to our feedback.

However, we identified shortfalls in the care and treatment of some people. There had been failures to safeguard some people from improper treatment or abuse. Gaps in the management team’s knowledge and explanations did not provide us with the level of assurance required. There was a lack of oversight of key high-risk areas of the service, including medicines management, risks relating to choking and the use of restrictive practices, including physical restraint.

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with felt able to raise concerns with the management team. They told us the interim manager was approachable and gave examples of changes that had been implemented as a result of feedback. However, staff raised concerns about the culture on some units and did not always feel able to raise issues internally when working on those units.

People and staff understood the procedures on how to speak up and escalate concerns.

The provider had not always worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a diverse workforce in place, and recruitment processes showed the provider employed staff from a variety of backgrounds. Feedback received from staff was mixed; whilst some staff members felt they were treated fairly, others felt this depended on the unit they were working, and the culture of the unit. Some staff shared examples where reasonable adjustments had been made to support their personal commitments, whilst others discussed incidents where they felt they had been treated unfairly.

This was fed back to the management team who were already aware of some of the concerns.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a lack of provider and managerial oversight of key areas of risk. A lack of investigations into incidents resulted in discrepancies and concerns not being picked up across the service. For example, there had been incidents of choking, yet the provider had not identified discrepancies in information about people’s diets shared across the service and care records.

Processes were not effective in ensuring restrictive practices were identified or appropriate documentation and authorisation were in place. Therefore, people had not always been protected from improper treatment and abuse.

Audits and walkarounds were in place but had not been effective in identifying areas of concern. For example, care plan audits failed to identify missing care plans and risk assessments for people, and actions had not always been followed up or signed off by managers. Walkarounds failed to identify concerns around infection, prevention control, or the disorganisation of people’s bedrooms.

Leaders had failed to recognise through their own quality assurance monitoring people were continually placed at risk of harm.

We were not assured systems to monitor staff training were effective, as records were not robust or up to date. We identified gaps in staff training records.

The provider developed an action plan following our feedback, and it was evident some action had been taken in response to this. However, the action plan in place prior to this, which the interim manager had been working from was not effective and had not identified some of the concerns we found.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider had built good relationships with external professionals. However, we identified gaps where information had not been followed up or clarified with professionals which led to inconsistencies in information and contributed to incidents occurring.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Systems in place to review accidents, incidents and trends, particularly in high-risk areas, were not effective in identifying inconsistencies and concerns we highlighted during the assessment. This limited the provider’s ability to drive continuous improvement and placed people at risk of avoidable harm. There was little evidence that learning from incidents was documented or shared with the whole staff team.