Bryony House

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 inadequate. At this assessment the rating has remained the same.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service remained in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 not successfully developed a strategy and culture which consistently promoted trust and understanding between them and the people using the service and focused on learning and improvement.

Although the provider, management and staff team told us they shared a focus on improving care for people, this had not always led to positive improvements. It was not always clear how the views and experiences of people with limited or fluctuating capacity were contributing to the development of the service. Managers and staff did not have a well-developed understanding of people’s rights around consent, which impacted upon their ability to uphold people’s rights.

Since the last inspection, there has been limited evidence to show what was learnt and how any improvements made had been embedded in the day-to-day culture and practice at the service.

The provider did not have leaders who fully understood the context in which they delivered care, treatment and support. Leaders did not have the skills and knowledge in some areas of care provision to lead the wider team effectively.

The registered manager had many years of care experience and staff spoke in mainly positive terms about their leadership. However, the registered manager told us they did not fully understand how to support people in line with Deprivation of Liberty Safeguards (DoLS) procedures and requirements. They also did not fully understand the need to seek consent and assess people’s ability to consent to care and treatment. The provider had failed to identify these shortcomings and ensure the management team were provided with the training and support they needed to lead in these areas.

Additionally, we found risks to people’s health and wellbeing were not consistently well managed. We found some evidence of poor culture around the support of people living with dementia. The management team had failed to identify the risks associated with issuing lists to staff telling them when some people should be woken and taken to bed within clear rationale for these or consideration of people’s own wishes.

We identified confusion amongst people and relatives about who the home manager was. We also found a lack of clarity in some cases about roles and responsibilities within the management team. Some people and relatives believed a staff member was the home manager, but they were part of the management team and not the home manager. Some relatives told us they had had little contact with the registered manager. They said they mainly dealt with other managers for day-to-day concerns. Some relatives were confused about who the deputy manager of the service was. Overall, most people and relatives told us they felt the management team were dealing with their concerns appropriately. However, confusion over management roles and responsibilities could lead to the registered manager not being fully aware of important information.

Some information provided by staff and relatives suggested the registered manager was not easy to access. However, some relatives told us they had spoken with the registered manager when they had needed to and had not had any issues with accessing their support.

Processes to support people and staff to speak up were not clear.

We found systems to support people and staff to speak up if they had concerns were not always made clear. We saw no evidence around the home of guidance for people on how to raise a concern or complaint. This included a lack of information in easy-read formats to ensure people living with dementia or visual impairment could access the information. However, most people we spoke with told us they felt confident to raise concerns if they had any.

A policy and procedure providing guidance for staff on who to share concerns with lacked clarity. We raised this with the provider who agreed to update the documentation.

Although there was a system in place to investigate complaints and concerns, the management team told us none had been raised since our last assessment.

The provider had failed to identify the potential risks and conflicts of interests associated with staff and managers being related to each other. There was no clear guidance in place on how staff could raise concerns about a staff member related to the management team. This left staff at risk of not feeling able to share concerns without detriment to themselves. The provider developed a procedure for staff to follow as a result of our feedback on this concern.

The provider valued diversity in their workforce. However, the staff team structure presented risks to their potential experiences of fairness and equity.

The implications of staff working with relatives of the management team had not been considered. The potential power imbalances this could create in the staff team had not been identified and mitigated. The provider ensured staff and leaders were representative of the population of people using the service. One staff member told us about reasonable adjustments which had been made for them and how they had benefited from this support.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

Many of the concerns we found during our assessment were not identified through the provider’s own quality assurance systems. This demonstrated a continued failure to manage and operate effective and robust quality assurance. Systems to monitor the recording, monitoring and analysis of falls had failed to identify people were not always receiving a timely response to their medical needs. They had not identified staff had not had the tools and training to provide consistently safe and timely care when people fell. Oversight of care provided had failed to identify the lack of consistent and effective practice in a number of areas. These included supporting people to remain hydrated; ensuring people were consistently and effectively monitored for signs of deterioration in their health; and ensuring people’s individual choices and preferences were always at the heart of their care, regardless of their mental capacity to make decisions.

Reviews of systems and processes had failed to identify people were not being supported in line with the legal requirements of the Mental Capacity Act 2005. Consent was not consistently sought. Where people were unable to consent to their care and may be being deprived of their liberty, applications for DoLS authorisations had not always been considered.

Systems to ensure staff were provided with training in line with legal requirements were not always effective. For example, staff had not been trained in line with the mandatory training requirement on learning disability and autism.

We saw limited evidence of appropriate checks and oversight of the work of the registered manager. As a charity, Bryony House was run by a board of trustees. The expertise of the various trustees was utilised for the benefit of the service. We saw some areas in which the service had clearly benefited as a result. For example, in the development plans for improved IT systems and in the maintenance of the safety of the building. However, there was no one with prior experience in managing or operating services like Bryony House that could support the management team. This meant gaps in the knowledge and skills of the management team around provision of care were less likely to be identified.

There was also a failure to ensure staff were not receiving performance checks and oversight of their work from related staff members. The challenge of providing unbiased feedback about staff to whom you were related had not been identified. This meant a staff member in this position may be at risk of not receiving impartial and effective oversight of care-related aspects of their role. This meant people were at increased risk of inappropriate care and treatment.

Although the provider worked in partnership with other services, their systems did not always enable people to get timely care and support. There was no specific policy and procedure to guide staff on how to monitor for health deterioration. This meant people were at risk of not receiving timely and appropriate support due to inconsistencies in staff decision-making regarding when to seek further support and care for them. We did see examples of joined-up care where people’s needs were identified by the staff team and met with support of other services and health professionals. These included the Speech and Language Team (SALT team), the local GP surgery, footcare and dental services. The management team were not engaging in meetings or events with other local care providers or networks to learn about and share good practice. This meant they may not benefit from possible support and learning these networks can provide. During our assessment the registered manager took steps to rejoin a service which facilitates local support networks.

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.

Although systems were in place to record and monitor risks and outcomes for people, they did not consistently enable the provider to ensure people’s care was constantly improving and safe. For example, checks were in place to monitor and record the competency of staff administering medicines. These checks were being used, but they had not identified the poor administration practice we saw during our site visit. Although falls analysis was being completed, it could not demonstrate strategies in place to reduce the risk of falls to people were actually working.

Although staff meetings were held, meeting minutes did not demonstrate opportunities to discuss and share lessons learned and good practice were taken. Although call bell response times were being regularly checked, the findings were not analysed in any detail. We saw no evidence for example of discussions with staff about the prolonged wait some people had before their call bell was deactivated. This meant opportunities to learn from the analysis were missed. Opportunities to regularly improve care for people were missed.