Bentley Court 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 legal regulation in relation to the governance at the service.

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. However, this had not yet been successfully embedded at the service. There were systems in place to check on the culture at the service and peoples experience. The management team had identified concerns relating to the culture which were discussed with staff in their meeting in January 2025. These concerns included staff not engaging people in conversation, not offering choices at mealtimes and not ensuring people were having the opportunity to get out of bed. Despite this, at the time of the assessment in March 2025 we found some staff were still not ensuring people were supported to meet their needs at the time of their choosing, were not engaging people in activity and conversation or offering support at mealtimes and were not consistently supporting people in line with their care plans. This meant the culture was not consistently person centred. Our conversation with 1 person confirmed how the culture at the service had the potential to impact people’s care experiences. They said, “I feel safe here and there are no concerns. I have never had to complain about anything. But I am stuck indoors, and I am in my room most of the time and it gets boring. I have never been out.”

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders had not ensured medicines storage systems were adequate. They had not identified topical medicines were stored in people’s bedrooms without a lockable facility to secure them. The leadership team had not been successful in acting to make changes to the cultural concerns discussed with staff. For example, staff not engaging people in conversation and not offering choices at mealtimes. However, staff spoke positively about leaders, with 1 staff member telling us, “The covering manager is new into the role, they are doing well. They are very professional, and complete floor checks every morning. They speak to all the staff and ask if we are ok.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and their relatives felt they were able to raise any concerns with the management team and felt these would be addressed if required. Staff told us they could also raise concerns and understood they could use a whistleblowing policy if these were not addressed. The provider ensured staff had information about how and where to raise any concerns they may have.

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. The provider had an equality and diversity policy in place which set out to ensure staff were able to work in an environment free from harassment, bullying, victimisation and unlawful discrimination. Staff were given training in understanding equality and diversity and shared no concerns about how they were supported by the provider.

The provider’s governance systems were not fully effective in identifying areas of concern and driving improvement. Checks on equipment were not consistently effective. A bed sensor was found to not be working and there was a fault with an air mattress which had a low-pressure light showing the checks in place had not identified these concerns or action taken to address this. Other audits and checks had also failed to identify areas of improvement. The call bell checks in place had not identified where call bells were not being answered for long periods of time. The provider used a dependency tool to determine the required staffing levels, however this was not accurately completed for 1 person at the home and therefore we could not be assured this was calculating the correct number of hours needed to support people. Other systems had also failed to ensure concerns were identified and action was taken including the medicines audits, care plan audits and checks on the quality of the care people received.

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. Partners told us the provider worked in partnership with them to make improvements to the service working through an action plan to make changes to the service as advised. They confirmed the provider responded positively to requests for data to monitor the quality of the care home. Leaders told us they had good relationships with partners and sought advice and guidance when needed. Health practitioners were consulted about people’s care needs and the advice given was included in people’s care plans.

The provider did not consistently focus on continuous learning and improvement. The provider had a service improvement plan in place. However, this did not include actions they were taking to address the concerns they had raised with staff in meetings about the quality-of-care people received and how they planned to make improvements. The provider recognised improvements were still needed and had begun establishing some processes including daily floor checks, and updated audit tools.