Breckside Park Residential 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 requires improvement. At this assessment the rating has changed to inadequate. 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 was in breach of legal regulation in relation to good governance and leadership.

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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The registered manager failed to promote a positive culture of good quality care. They lacked the ability to identify and challenge staff for poor practice. For example, the provider had not developed a statement or strategy outlining the organisations future plans and goals and how they were to be achieved to ensure positive outcomes for people. This was confirmed by the registered manager. The registered manager did not always recognise and address poor practice with staff including safety concerns and a lack of respect and dignity for people.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. For example, the provider and registered manager failed to implement the objectives as set out in the providers Statement of Purpose (SoP). The SoP stated ‘The home offers a high standard of care at all times’ however; this was not our findings during this assessment. The provider and registered manager did not always demonstrate they understood their role and responsibilities for ensuring people received high quality care.

The registered manager did foster a positive culture where people felt they could speak up however leadership in the whole needed to be improved. For example, we found no evidence any employee had spoken up about the issues we found whilst on inspection. People did however tell us they knew how to speak up and their voice would be heard. For example, one person told us “I know how to complain, [registered manager] is always available and very approachable.”

Despite the provider valuing diversity in their workforce and working towards an inclusive and fair culture more improvement under leadership was required overall to ensure staff were fully supported and included.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. For example, there was an overall lack of oversight and scrutiny of the service by the provider and the registered manager to ensure risks were identified and mitigated. Audits and checks were not always completed to monitor, assess and improve the quality and safety of the service. The registered manager told us they had completed daily walkarounds to check on the safety of the environment, equipment and staff performance. They confirmed the provider visited the home regularly and carried out checks. However, the registered manager confirmed they did not maintain any records of their checks and findings and nor did the provider. The registered manager confirmed there was no process in place for auditing peoples care plans and associated records to ensure they accurately reflected people’s current needs. The provider had a set of policies and procedures setting out expected standards and safe working practices. Despite this there was a failure from staff at all levels to ensure these were followed.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. For example, the provider told us they engaged with external professionals to make improvements. However, we were not assured priorities had been effectively assessed as concerns remained regarding fire safety and the safety of some aspects of the home environment. People and their relatives told us they received support to access services from other health care professionals as needed, such as their GP or speech and language therapist (SALT). Feedback from external professionals was generally positive in terms of how the provider engaged with them to review and meet people’s needs.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe and effective practice. For example, a lack of analysis of events such as accidents and incidents led to missed opportunities to make improvements to avoid further occurrences. Although there was a service improvement plan in place it did not identify or address many of the longstanding concerns, we found during this assessment. On our first site visit day we provided feedback to the registered manager and provider based on our findings. Despite this there were no improvements made by our second site visit day.