During an assessment under our new approach
Date of assessment 29 April to 15 May 2026. The assessment was conducted to review the progress of the provider from the previous assessment in May 2025. The assessment was comprehensive and included a review of the rating of all key questions. The service is a residential care home providing support to up to 35 older adults including those living with dementia. There were 21 people living at the service at the time of our assessment.
At our last assessment we found breaches of 5 regulations. These were in relation to treating people with respect and dignity, providing safe care and treatment, protecting people from the risk of abuse and neglect, the management of safety of the environmental and governance systems.
At this current assessment we found breaches of 4 regulations. We found continued breaches in relation to safe care and treatment, protecting people from the risk of abuse and neglect, and governance systems. We found a new breach in relation to seeking consent from people. We found the service was no longer in breach of regulations relating to treating people with respect and dignity and the management of the safety of the environment.
Everyone living at Bryony House had had an assessment of their needs and risks and these were reviewed regularly. However, we found the information and guidance in some people’s care plans was not accurate, up to date and complete, including a lack guidance for staff about some people’s key health needs.
Although some aspect of medicines management had improved, we found ongoing concerns around medicine stock management, support for self-medication and medicine administration practices.
The home environment had been risk assessed and control measures were in place to allow people to live in a safe home environment.
Systems to record, monitor and analyse falls and risk of falls were not always effective. This meant people were not fully protected from avoidable harm. The provider had failed to ensure people were consistently appropriately assessed following falls to facilitate prompt medical care for any resulting injuries. The provider also failed to ensure staff always effectively monitored any deterioration or changes in people’s health, including signification reduction in fluid intake.
The provider failed to assess and manage potential conflicts of interest within the staff team. We found a lack of effective audits and checks to assess, monitor and improve the quality and safety of people’s care.
We found safeguarding concerns had not always been addressed appropriately to ensure the safety of the person at risk of abuse. We also found 2 examples of inaccurate information being shared with the local authority safeguarding team. We saw other safeguarding concerns which were investigated and shared with other services appropriately.
Although we saw sufficient staff supporting people, the provider had not always ensured staff had the training needed to provide safe and effective care. The provider was using DBS (Disclosure and Barring Service) checks to determine staff’s safety and suitability at the point of recruitment. However, there were no systems in place to review the safety and fitness of staff who had remained employed at the service for many years.
The provider did not consistently apply the principles of the Mental Capacity Act 2005. People’s consent to care had not always been sought or recorded, their ability to make specific decisions had not always been appropriately assessed or reviewed and it was not always clear the decisions taken or restrictions introduced on people’s behalf had been done in their best interests. People’s rights and protection under the Deprivation of Liberty Safeguards (DoLS) were not fully understood or upheld.
The provider could not always evidence that the views of people living with dementia had been fully considered when delivering their care.