Broadoaks

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

The key question of well-led was rated as requires improvement at our last inspection. At this assessment the rating has improved and the key question of well-led is now rated good. Systems and processes were effective to ensure good governance and oversight.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders shared common vision for the home and the same values. Staff told us what their aim was, “To create a home from home and provide a good quality of life.”

The home had a clear statement of purpose and description of the values which the staff team aimed to work in line with. The values included privacy, dignity, independence, choice and fulfilment.

Staff valued the management team and felt they were approachable and competent leaders. Staff told us, “[The registered manager] is approachable. I feel like if I have problems, I can go to anyone in the building. I can ask for more training, and I can swop shifts when needed.”

It was clear that staff and families felt the registered manager was approachable and compassionate. The manager’s office was in the heart of the home close enough to be able to respond to staffs needs for support.

Staff knew how to raise concerns and felt comfortable to do so when needed. Staff attended monthly team meeting, this included night staff.

Staff received supervision and one to one time with the management team to ensure their personal and professional development needs were met. Staff told us they can ask the registered manager for items needed or suggest new ideas and the manager listens.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager told us that they completed checks on the quality of the service. The manager was able to tell us what lessons they had learnt as a result of a complaint. The registered manager said they would work on introducing clear ways of working to better link lessons learnt to incidents that occurred. This was to ensure clear oversight of what has happened, been learnt and to ensure that improvements are sustained. The registered manager told us there were clear lines of communication and all staff understood their specific areas of responsibility. Feedback from staff confirmed they understood their responsibilities and how to communicate concerns internally.

The management team carried out a range of audits and checks such as care plans audits, mealtime audits, nutrition audits, infection prevention and control or medicines audits. They attended meetings where people’s risks and needs, as well as actions taken by staff were discussed and agreed. The registered manager told us they complete pre-assessments and ongoing assessments of peoples needs. They told us they include environmental aspects of the home as part of the assessment for suitability such as the staircase.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

A stakeholder said, “When I visit, the manager or senior carer is always involved with the actions required and I have seen good note-keeping practices.”

There was no process or system in place to analyse safeguarding matters to identify themes and trends, learning and reduce the risk of reoccurrence for incidents such as falls. This means it would not be easy for the registered manager to identify how many falls each person has had, or if one area of the home is more prone to people falling. There was, however, good recording on incidents on an individual bases. The registered manager was open to our feedback to use best practise and introduce a process to help quickly identify trends. Staff had safeguarding training, however there was no systems in place to further explore their understanding of the subject. We found some staff did not know how to report concerns externally to the local authority and CQC. Systems for checking staff have read and understood care plans were not always effective, two staff told us they had not read all care plans.