Bethany House 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 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 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 service was in breach of the legal regulation in relation to governance.

This service scored 61 (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.

People who had lived at the service for many years told us they felt comfortable and experienced the service as warm and homely. Staff provided care that reflected the provider’s aim to deliver individualised support in a friendly setting. They understood the importance of treating people with dignity and respecting their wishes. The atmosphere was welcoming, and people appeared comfortable and relaxed around staff and managers. One person told us, “I know [Registered Manager] and all the staff are very receptive to ideas.” A relative told us, “I haven’t got any concerns about this place or its management.”

Not all leaders demonstrated a clear understanding of the context in which care was delivered. The provider and registered manager had not ensured consistent oversight of the running of the service, which led to breaches of legal regulations in some areas. Governance systems were not always effective, and audits had failed to identify issues with care records and aspects of the premises in disrepair.

However, the registered manager was dedicated to the staff team and the people using the service. They were receptive to our feedback and committed to making improvements. People and staff spoke positively about the registered manager, describing them as approachable and supportive. One staff member told us, “[Registered manager] is very supportive, their door is always open. I speak to them most days.” There was an evident culture of kindness and compassion within the service, despite the governance challenges.

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

Posters were displayed in the service advising staff how they could raise concerns, and the Registered Managers door was always open. People and their relatives were provided opportunities to discuss their care. One person told us “I know [Registered manager], [they] are really approachable.”

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 felt valued and well supported by managers. There was a diverse workforce, and no staff reported discrimination, and they felt confident this would be addressed appropriately by the registered manager if it occurred.

The provider did not have clear responsibilities, roles, systems of accountability and good governance.

The provider and registered manager had not ensured consistent oversight of the service, which led to breaches of legal regulations. Governance systems were not always effective, and audits failed to identify key issues, including environmental risks, gaps in care records, and incomplete training. Care plans were inconsistent, and documentation for medicines such as transdermal patches was unclear. Staffing arrangements lacked a clear strategy, and we observed occasions where people waited for support. Supervision and appraisals were inconsistent, and some incidents were not investigated or reported in line with the provider’s policy.

Despite these concerns, the registered manager was committed to people using the service. They were receptive to feedback and had begun reviewing audits with plans to implement an electronic system. People and staff spoke positively about the registered manager’s approachability and support, which helped maintain a caring and homely atmosphere.

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

Staff worked in partnership with community agencies and made appropriate referrals to ensure people received any specialist support they needed. Community healthcare professionals who visited the service told us people were happy and well cared for. They told us management and staff were friendly and approachable, and the quality of care provided was good.

The provider did not always 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. They did not always actively contribute to safe, effective practice and research.

The provider’s governance systems did not include effective processes to learn lessons when things went wrong. Incidents and complaints were not always analysed to identify trends or prevent recurrence, and there was no structured approach to improve practice and strengthen safety. Leaders acknowledged these gaps during the inspection and told us they were reviewing systems to ensure lessons learned are captured and acted upon in the future.