Broom Lane

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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 81 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff consistently reported and reviewed incidents, including those involving harm, restraint or external agencies. Following incidents, staff took part in structured reflection to identify what had happened, understand contributing factors and agree changes to support. This learning was shared across teams and applied in day-to-day practice.

People were involved in reviewing incidents in ways that reflected their communication needs and preferences. Their feedback led to changes in routines, environments and support approaches. For example, adjustments to support following episodes of distress helped some people become more settled and reduced the likelihood of similar incidents occurring.

Staff described discussing incidents and learning in team meetings and applying agreed approaches consistently. This resulted in more predictable support, which helped reduce risks and supported people to feel more settled. Staff were able to explain how changes in practice had improved safety and reduced incidents for individuals.

Leaders reviewed information about incidents, behaviour and staffing to identify patterns across the service. They used this information to make targeted changes, such as adapting support strategies or staffing arrangements, and monitored the impact over time. Where changes were effective, these were embedded into practice across the service.

Learning led to sustained improvements in care. Some people experienced a reduction in incidents of distress following consistent use of updated support strategies, and care became more consistent as staff applied shared learning. Improvements were reviewed and built on over time, resulting in continued reductions in risk and more stable support for people.
 

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 experienced stable and consistent support. Staff knew people well and shared information within the team so care reflected each person’s needs, preferences and risks. When needs changed, staff adapted support, including adjustments to routines and staffing, so disruption to people’s day-to-day lives was minimised.

Staff recognised changes in people’s needs and responded appropriately. Risks were reviewed and care was updated in a timely way, helping to ensure people continued to receive safe and suitable support. Staff worked with health and social care professionals, families and others involved in people’s care to review and agree changes. Information was shared between services to help ensure continuity when support was adjusted or when people moved between different levels of care.

Transitions and changes in support were managed so people continued to receive consistent care. People were supported by staff who worked together with others to maintain continuity, helping to ensure their safety and wellbeing as their needs developed.

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.

Safeguarding processes were well established and consistently applied. Concerns were identified and acted on promptly, with evidence of timely escalation, thorough investigation and clear recording of decisions, actions and outcomes. Learning from incidents was shared and used to improve practice across the service.

Risk was managed proactively, with staff taking appropriate and proportionate action to reduce harm. Safeguarding was embedded within wider governance systems, and leaders maintained oversight of themes, risks and learning to support continuous improvement.

People can only be deprived of their liberty with appropriate legal authority. We checked how the provider identified when care arrangements may amount to a deprivation of liberty and ensured appropriate authorisation was sought. Staff demonstrated a clear understanding of this and worked with relevant professionals to seek legal authorisation, such as through the Court of Protection, where required.

Staff applied the principles of the Mental Capacity Act 2005 (MCA) in day-to-day practice. They supported people to make decisions where possible and followed best interests processes when capacity was lacking. Support was delivered in the least restrictive way, with arrangements regularly reviewed and adapted to ensure they remained appropriate and supported people’s independence and choice.

People experienced care where safeguarding concerns were acted on promptly, risks were reduced and their rights were respected. There was a consistent approach to least restrictive practice, enabling people to remain safe while maintaining choice, control and independence.
 

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People were actively involved in decisions about their daily lives. Staff explained risks in a way people could understand and adapted support to reflect individual preferences. This meant people were able to continue with activities and community involvement safely, rather than being unnecessarily restricted.

Staff consistently responded to how people communicated, including non-verbal cues. They adapted or stopped support when people showed they were uncomfortable or did not want to continue. This ensured that risk management remained aligned with people’s wishes and reduced the likelihood of distress.

Risk management approaches were structured and tailored to each person. Positive Behavioural Support plans identified triggers, early warning signs and clear strategies for staff to follow. Staff applied these approaches consistently, which helped reduce the likelihood of escalation and supported more predictable and stable care.

Leaders and staff reviewed risks regularly and used information from incidents and day-to-day practice to refine support. Restrictive practices were monitored and reduced over time, with a focus on proportionate and least restrictive approaches.

Staff worked with health and social care professionals to review and adapt risk management. Strategies were updated over time and shared across the team, ensuring a consistent and coordinated approach.

As a result, people were supported to take positive risks and maintain independence. Care enabled people to do what mattered to them, while risks were managed safely and consistently, leading to improved stability and reduced reliance on restrictive interventions.
 

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

The environment was clean and well maintained, and people appeared comfortable and confident in their surroundings. There were no immediate safety concerns observed.

Staff identified environmental risks and took action to address them. Maintenance issues were reported and followed up, and changes were made where needed to reduce risks, including after incidents. Staff followed fire safety procedures and took part in training and evacuation drills.

Leaders checked the environment and followed up actions to ensure issues were addressed in a timely way. People lived in an environment that balanced safety with comfort, where risks were identified and managed appropriately.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Recruitment processes were followed, with appropriate checks completed before staff started work. This helped ensure people were supported by staff who were suitable for their role.

Staff completed induction and training, and their competence was assessed. Staff were supported through supervision and day-to-day oversight, which helped ensure they were able to carry out their roles effectively.

Leaders monitored staffing and supported staff development. There were opportunities for staff to progress within the service, which contributed to a stable workforce.

People experienced care from staff who were appropriately recruited, trained and supported, and who knew their needs well.
 

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.

Communal areas and shared spaces were visibly clean, and appropriately maintained. Hand hygiene facilities, including soap, sanitiser and PPE, were available where required.

Staff followed infection prevention practices in their day-to-day work. They understood when to use PPE and took appropriate precautions during tasks such as personal care and cleaning.

Arrangements reflected a supported living environment. Equipment was stored appropriately, and care was delivered in a way that avoided an overly clinical or institutional feel while still managing risks.

Visitors were asked to report any symptoms of illness, and appropriate measures were taken when risks were identified.

People experienced care in an environment where infection risks were managed, and there were no recent outbreaks or significant concerns.
 

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.

Staff supported people with their medicines in a way that reflected their needs and preferences. Medicines were planned for and reviewed as part of people’s care, including when changes were required.

Staff understood how to use medicines safely, including ‘as required’ (PRN) medicines. They recognised when these were needed and described using other approaches, such as providing reassurance or adjusting support, before administering medicines where appropriate.

Staff worked with health professionals, including GPs and specialists, to review people’s medicines and make changes when needed.

People received their medicines safely, and there was no evidence of harm or misuse. Medicines were used appropriately and as part of people’s wider care and support.