Archived: Brenan House 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 inadequate. At this assessment the rating has remained 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 governance at the service and registration regulations relating to submitting notifications and complying with conditions on their registration.

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 provider did not have a vision for the service and did not promote a positive culture. The registered manager did not hold staff meetings to discuss the culture and direction of the service. The provider sent us their statement of purpose, this was a generic document, the specific information relating to the service had not been added. For example, there was no information about the providers aims or objectives for the service. The document had not been signed or dated.

Leaders did not have the skills, knowledge, experience and credibility to lead effectively. The provider and registered manager did not have up to date knowledge and training to make sure the service was meeting the regulations. We discussed the shortfalls we found at the inspection with them. They did not understand what was required of them as providers and leaders to meet the regulations. The registered manager did not have any up to date general or management training, they did not have the skills and knowledge to lead the staff team to make improvements in the service.

There had been no improvement in the quality of the service at the last 3 inspections and there had been a marked deterioration since our last inspection in January 2023.

There was no effective system for people to give their views. There had been no resident, relative or staff meetings so concerns could be raised and discussed or suggestions made. Staff told us they would speak to the registered manager if they had any concerns and thought they would sort the concern out. The provider’s complaints policy was a generic document and not specific to the service. The policy refers to a complaints manager but one has not been identified. There was no information about who to make complaints to or who to complain to if they are not happy with the provider’s response. The policy had not been signed and dated by the provider. The policy was not available in the home and was not available in an accessible version. Relatives told us they would speak to the registered manager if they had concerns but had not felt the need to do so.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they were treated equally and enjoyed working at the service. The provider had a range of policies to support staff. However, these were not specific to the service and the provider had not followed them, for example, staff had not received supervisions.

There is no reference in the policy about valuing the different cultural backgrounds of staff or how they will support staff and people to understand each other’s cultural and spiritual needs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. There were no effective systems in place to monitor the quality of the service. The provider had not met the positive condition on their registration, they had not sent in monthly reports as required or submitted notifications as required for the last year. We discussed this with the provider and registered manager, who told us they had trouble using the CQC provider portal. They had not contacted CQC or used the email as included on the CQC website.

The provider had not completed any checks and audits on the quality of the service and the significant shortfalls found at this inspection had not been identified.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. The registered manager worked with the GP and district nurses to make sure people received the support they needed. People were referred to healthcare professionals as needed. The registered manager was not part of local groups or forums and had not acted to integrate the service into the local community. People had not been supported to take part in local groups or activities.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. The provider had a task orientated focus within the service which did not support good quality person centred care. The registered manager had not acted to support learning or changing the way the service provided support. The provider did not evolved the care to provide holistic support and consider people’s wellbeing.

The provider had not taken opportunities to improve the service including accessing local or national groups which provide support and learning.