Broomgrove Trust Nursing 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 remained 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 provider was previously in breach of the legal regulation in relation to the governance of the service. Sufficient improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 did not have a clear shared vision, strategy and culture throughout the whole staff team. Systems and processes had not ensured that all staff worked consistently across the service. Feeback from people and relatives relating to the experience of care was mixed, with some people reporting their experience was dependent on the staff member present or the time of the week. A relative told us, “Sometimes staff haven’t put [my relative] in the correct clothing or underwear, weekends are the worse for this.” A person told us, “Some staff are better than others. There is no management around on a Saturday or Sunday, but I think there should be because things get a little lax.”

A registered manager was in place at the service, in line with current legal requirements. Where concerns were raised regarding staff culture, records showed that corrective action was taken by the leadership team on site.

The provider fostered a culture where people felt they could speak up and their voice would be heard. Staff told us they found managers approachable and could discuss concerns they had. Policies and procedures were in place to manage whistleblowing.

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. Staff told us they felt supported by the management team at the service. Staff reported that as a staff team, people worked together well and supported each other.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Records contained inconsistent information regarding peoples care needs, and daily records indicated that interventions intended to reduce the risk of physical decline were not completed to agreed standards. Although auditing and governance checks were taking place, these had not identified issues in record keeping. Records documenting a person’s fluid intake had reduced below agreed levels over a sustained period had not resulted in action by the service to address this or seek medical advice. Staff told us they did not routinely read people’s care plans, instead relying on daily handover notes. There was no record of who in the staff team knew about changes to people’s needs when these occurred. Checks which were in place to monitor daily records had not been effective in identifying where care had not been delivered in line with agreed plans. An electronic care planning system was in use which had the functionality to alert staff members to missed care intervention. However, this feature does not appear to have been effective in ensuring care was delivered consistently in line with agreed plans. Staff did receive supervision sessions, although records indicated these were not individualised to the staff member and did not consist of a two-way conversation exploring staff understanding of tasks or any challenges to delivering care that may be in place. Of the supervision records reviewed, 2 were identical. Feedback from staff was not routinely gathered or used to make improvements to the service, managers advised that this was previously in place but due to a poor completion rate by staff this was no longer taking place, an alternative method of gathering feedback from staff formally had not been introduced.

The provider understood their duty to collaborate and work in partnership. They shared information with partners. Records were available to be shared with health and social care professionals as required. Where people required support from outside services, for example for appointments, the service ensured these were arranged.

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. They did not always actively contribute to safe, effective practice. Gaps in care provision had not always been identified, so had not been used to support improvement. Feedback from staff was not sought formally to support with service improvement.