Broom Lane

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 outstanding. At this assessment the rating has remained outstanding.

This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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.

Leaders promoted a positive and inclusive culture based on clear values such as respect, openness and involvement. Staff described a supportive environment where they felt able to share ideas, raise concerns and seek support. They said managers were approachable and listened to feedback, and gave examples of changes being made as a result.

Staff were encouraged to develop in their roles and contribute to improvements in practice. They took part in meetings and day-to-day discussions where information was shared and ideas were discussed. Leaders used information from the service and feedback from staff to make decisions and improve how the service operated.

People benefited from a staff team that worked collaboratively, supported each other and were engaged in delivering consistent, person centred care.
 

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Staff consistently described leaders as approachable, visible and accessible. They said leaders were available to provide support, responded to concerns and were actively involved in the day-to-day running of the service. Staff gave examples of raising ideas and issues which led to changes in practice, reflecting a responsive and engaged leadership approach.

Leaders demonstrated a strong understanding of the service and the needs of both people and staff. This was supported through direct observation, regular presence within the service and ongoing engagement with staff teams. Leaders were aware of risks, service pressures and staff wellbeing, and took action to address these.

Systems were in place to support leadership oversight, including safeguarding processes, incident review and monitoring of practice. Leaders used these systems to identify issues and implement changes, including improvements to care delivery and the environment. Leadership visibility, including spot checks and direct engagement, supported real-time awareness of quality and safety.

People’s experiences reflected effective leadership oversight. Care continued to support engagement in meaningful activities, with leaders ensuring that risks were managed in a way that maintained independence and participation. Decisions about care, including restrictions, involved appropriate review and consideration of least restrictive options.

However, while leaders encouraged openness and engagement, evidence of staff feedback was primarily based on individual examples rather than structured, organisation-wide systems. There was less evidence of formal mechanisms to gather and analyse staff voice at scale to inform leadership decision-making over time.
 

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

Staff said they were confident to raise concerns and discuss ideas with managers and colleagues. They described leaders as approachable and responsive, and gave examples of feedback leading to changes in practice.

Staff spoke about sharing concerns through day-to-day communication and team discussions. They felt their views were listened to and acted on. Leaders encouraged open communication and used staff feedback to make improvements to the service.

People benefited from a service where staff felt able to speak up, supporting a culture of openness and continuous improvement.
 

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.

Staff described a working environment where they felt able to raise personal and work-related issues with managers and colleagues. They said leaders were approachable and took action to support them, including making adjustments to meet individual needs where required.

Staff experience reflected fair treatment in practice. They told us they had access to development opportunities and were supported to progress in their roles. Staff were able to discuss concerns openly and said they received support when needed.

Leaders knew staff well and were visible within the service. They engaged with staff on a day-to-day basis and responded to individual needs, helping to ensure staff felt included and supported at work.

People benefited from a staff team who felt respected and supported, which contributed to consistent, person centred care.
 

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

Leaders operated structured governance processes across daily, weekly, monthly and quarterly cycles. We reviewed records showing that these systems brought together information about workforce performance, safety and care delivery. Leaders used this information to monitor trends and respond to risks in a timely way. Workforce data, including absence, lateness and retention, was routinely reviewed and informed management decisions.

We saw that risk management systems were embedded in practice. Staff recorded incidents, behavioural data and care information, which leaders reviewed to identify risks and take action. This enabled earlier identification of concerns and supported targeted interventions when risks increased.

Records showed that governance processes led to action. Leaders identified issues, assigned actions and monitored progress through governance systems. These actions included addressing workforce performance and making changes to care delivery. This meant that governance systems translated into practical improvements in how the service operated.

We reviewed evidence showing measurable improvement in key areas. Workforce data showed reductions in absence and lateness over time, which improved staffing stability. Records also showed improved consistency in care delivery linked to increased oversight and structured monitoring.

Leaders were visible and actively involved in the service. Staff told us that leaders monitored performance and responded to issues. Systems were effective in identifying and responding to concerns, and there were examples of governance activity leading to sustained improvements in practice, although the consistency of how this impact was evidenced across all areas varied.
 

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

Partnership working led to clear improvements in care delivery. Multi-disciplinary input resulted in timely adjustments to support, including changes to staffing and behavioural strategies. This supported improved engagement, independence and access to community opportunities for people.

Partnerships extended beyond individual care and contributed to wider organisational and community outcomes. There was evidence of collaboration to support workforce development, including community based recruitment initiatives, and engagement in sector learning and accreditation processes. The provider shared learning and practice with others, contributing to wider system development.

Processes to support partnership working were embedded and consistent. These included multi-disciplinary review processes, safeguarding arrangements and governance systems to support communication, information sharing and monitoring of actions. Data was shared with partners to support decision-making and coordinated responses.

Leaders demonstrated a proactive approach to partnership working, including engagement in system level initiatives and collaboration with external organisations to support service improvement and sustainability.
 

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

Leaders regularly reviewed information about people’s care, including behaviour, incidents and outcomes, to identify patterns and areas for improvement across the service. This information was used to agree actions and implement changes to support approaches, staffing and daily routines.

Staff were actively involved in learning and improvement. They reflected on incidents, shared learning with colleagues and consistently applied changes in their day-to-day work. Learning was embedded in practice, which supported more consistent approaches to care across the service.

Leaders reviewed the impact of changes over time and used this information to refine approaches. Learning was revisited and built on, ensuring that improvements were maintained and continued to develop rather than being one off changes.

These approaches led to sustained improvements in people’s experiences. People became more settled and engaged, and some experienced reduced behaviours of distress following consistent use of updated support strategies. Improved staffing arrangements also supported continuity of care, which contributed to more stable and predictable support for people.

Learning was used not only to respond to issues but to drive ongoing improvement. People benefited from a service that continued to develop its practice, with changes leading to better outcomes and more consistent, person centred care over time.