Broughton 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 good. At this assessment the rating has changed to 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 in breach of legal regulation in relation to governance.

This service scored 57 (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 always share their vision and strategy. For example, the provider did not work collectively with the staff team to plan and promote a safe and pleasant environment for people. However, the registered manager promoted a positive, inclusive and person-centred culture. They did this through regular training sessions for staff, meetings and supervisions.

The provider did not always provide assurances they had the skills, knowledge, experience to lead effectively. For example, the provider did not operate a formal process for supervising the registered manager. Despite our requests the provider failed to evidence how they supported the registered manager in their role, with their professional development and how they, as the provider ensured the quality of care provided.

However, the registered manager provided staff with guidance and regular updates about the service. Staff and others were complimentary about the registered manager describing them as capable, supportive and inclusive. Staff comments included, “[Manager] has a lot of experience and is very good. Always keeps us in the loop” and “[Manager] knows their stuff and all the residents. Really good manager, very supportive.” A family member said, “The manager is approachable, and I would be able to say if things weren’t right, I’m happy with the way the place is run for [relative]” and a healthcare professional said, “[Registered manager] is very approachable and professional in responding to any concerns.”

The registered manager fostered a positive culture where people felt they could speak up and their voice would be heard. For example, there were systems and processes in place for staff to speak up confidentially should they need to, including a whistle blowing procedure. Staff confirmed the registered manager operated an open-door policy whereby they felt confident about speaking up and they felt they would be listened to. Staff comments included, “[Registered manager] is easy to talk to and listens” and “[Registered manager] always listens and takes note of anything we say.”

The registered manager valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. For example, a diverse staff groupwith a wide range of backgrounds and experiences were employed.The registered manager shared information with staff about independent services they could contact should they need support with their health or wellbeing in confidence. Staff told us any requests for flexible working patterns were agreed.

The provider did not always the have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. For example, the provider did not effectively assess, monitor and improve the quality and safety of the environment and equipment. The provider failed to identify and act upon risks we identified during our assessment site visit. This included hazards associated with both inside and outside of the premises and equipment. Whilst the registered manager recognised these areas of risk, they relied on the provider who held the responsibility for the budget. We gave the provider multiple opportunities to share details of their plans for improving the safety of the environment and equipment, however, they failed to respond.

The registered manager maintained detailed records of regular checks and audits they completed including care plan and medicine audits and checks on staff performance. Staff had access to a range of current policies and procedures to guide them on safe and best working practices.

The registered manager understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. For example, the registered manager explained how they worked in partnership with other organisations, including the local authority commissioning and safeguarding teams, dietician’s, mental health teams and speech and language therapists. Multidisciplinary meetings (MDT’s) took place regularly and attended by other health and social care professionals who offered advice and shared good practice.

The provider did not always enhance service delivery and demonstrate a commitment to continuous improvement. For example, the provider failed to identify and make improvements to the premises and equipment. Parts of the home both inside and out and some items of equipment were unsafe due to the lack of maintenance and repairs. The registered manager confirmed the provider visited the home regularly and carried out checks including checks of the environment. Despite this the provider did not maintain any records of their checks. In addition, the provider had not developed a plan for future improvements.

The registered manager maintained a record of events such as incidents, accidents and safeguarding concerns. The records detailed lessons learnt, and improvements made to reduce the risk of further occurrences.