- Care home
Bryony House
We have imposed conditions on Bryony House Limited on 2 October 2025 for failing to ensure people were safe from avoidable harm and for failing to ensure people received their medicines safely and as prescribed. The provider also failed to have effective quality checks in place to identify improvements or to drive improvements in care at Bryony House.
Assessment report published 1 August 2025
Contents
Ratings
Our view of the service
Date of Assessment: 20 May and 28 May 2028. The service is a residential care home providing support to 26 older people including those living with dementia.
The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.
However, the information shared with CQC about the incident indicated potential concerns about the management of risk of harm to people from the lack of appropriate assessment of need. This inspection examined those risks
We found breaches of the legal regulations in relation to safe care, safeguarding, the physical environment, treating people with dignity and respect and governance.
Not everyone living at Bryony House had a full assessment of their needs or potential risks putting them at the risk of inconsistent care which failed to meet their needs. The provider did not consistently assess people’s health needs or develop guidelines for staff to work to ensure people received a positive outcome.
People could not be assured they would receive their medicines safely or as prescribed. The provider failed to have appropriate systems in place to identify when medicine stocks were running short. The provider failed to follow best practice guidelines when supporting people with covert medicines. The provider failed to have effective checks in place to ensure people received their medicines with sufficient safe gaps in between doses.
People could not be assured they were protected from avoidable harm as the provider failed to complete effective checks on the physical environment. When risks were known, or suspected, the provider failed to risk assess these risks to minimise the risk of harm or reoccurrence.
People could not be assured they would be protected from abuse or ill treatment. When incidents occurred, the provider failed to follow locally agreed guidance for reporting and investigating incidents. When concerns were expressed to the management team these were not consistently recorded or acted on. The provider did not consistently follow the principles of the mental capacity act when making decision for people putting them at the risk of having their rights eroded.
People were not always treated with respect and dignity by those supporting them. Daily records regarding people contained judgemental and disrespectful statements which was devaluing. Some interactions between staff and people were disrespectful.
Not everyone living at Bryony House had a care and support plan detailing their likes, dislikes, needs and aspirations. Not everyone had their future wishes recorded.
The provider did not have effective checks in place to identify improvements in care and people’s experiences.
The provider followed safe recruitment procedures when appointing new staff.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
People and relatives gave mixed feedback regarding their experiences of care at Bryony House. Some relatives found their relative to be safe and protected from the risk of harm as staff regularly popped in to ensure they were safe, and another felt staff were competent and safe when using a hoist.
However, others found the staff did not follow up on falls or incidents as they expected and they didn’t feel involved in planning their relative’s care.
Relatives felt staffing levels were OK but were not sure they were sufficient during the weekends. One relative told us they had to go looking for staff at the weekend to support their family member when they needed it.
People and relatives were positive about the staff who supported them and their family members and felt there was a core group of staff who knew them well. One relative felt staff knew their family member well and responded to them when they were upset. However, they felt there was a lack of entertainment and stimulation within Bryony House.
We received mixed responses on how people’s medicines were managed. One relative felt they had to consistently ask the management team for a review of their family members medicines and felt removed from any discussions. Whilst others felt the medicines were managed well and there were no problems.
People gave mixed responses regarding the management of Bryony House. Some felt the service was well managed whilst others did not feel fully engaged with the management team of decisions about their family members.