Brightwater

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

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires improvement. This meant governance and oversight of the service was inconsistent.

This service scored 62 (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 a shared vision and person-centred culture. There was a positive listening culture, focused on learning and improving outcomes for people. We received consistently good feedback and made positive observations about the culture within the home. A person told us that they trusted and felt comfortable with staff, and comments from relatives included, “At the moment there’s nowhere better for [my relative]” and “The company and whole home’s ethos is about the importance of caring for each other as well as residents”. Staff told us, “I like to think we’re the happiest home in Hampshire” and “I love my work, I really enjoy it. I come to work and it’s just a really happy environment to work in”. The registered manager was open and responsive to feedback throughout our inspection.

Management in the service embodied the culture and values of their workforce and organisation. A relative told us, “[Registered manager] is always available for a chat and always resolves things”, and a staff member said, “He always chats with staff and residents to see how everyone is and involves people in everything”. Allfeedback we received about the registered manager from people, relatives and staff was positive. However, as the regional manager, had additional responsibilities overseeing 2 other services. The service had a deputy manager and a peripatetic deputy manager, who we also received positive feedback about, but the provider’s senior management structure had not ensured the provider had sufficient oversight of the service. Although the registered manager told us they felt supported, shortfalls identified meant we could not be assured appropriate systems and support mechanisms were in place. The provider had also identified this as a shortfall, and a new Head of Care had recently been employed to improve this.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff comments included, “Any ideas will be heard and discussed”, “[Management] always ask me if I have any opinions or want to suggest any changes. It makes me feel involved and that my opinion matters”, and “Teams are always confident in speaking up and giving their ideas which I love”.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although we did not find evidence of negative impact on people, the provider did not have robust and effective systems and process to ensure oversight and good governance. This meant the provider could not be assured shortfalls would be identified, particularly when the registered manager was not present in the service. The provider’s lack of robust processes meant there was exposure to the risk of harm. Although audits were completed at service level, these were not alwayseasily accessible and had not identified some of the shortfalls we found during our inspection. For example, in relation to environmental risk assessments and capacity assessments. The last provider audit was completed in October 2024 and covered the period of time since July 2023. This had not identified some of the shortfalls we found. When shortfalls and actions had been identified, not all of these had been put on the service improvement plan. When they were, they were not always completed in a timely manner. The registered manager told us the provider had recently employed a new Head of Care who would now be supporting and making improvements to governance and oversight. The provider had also sourced an external consultant to complete a full audit, although this had not yet been completed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.