Bricklehampton Hall

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 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 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 provider was in breach of the legal regulations relating to good governance.

This service scored 29 (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. There had been no attempt to update the statement of purpose to reflect the service and management of the service. This did not demonstrate any evolution of vision or strategy to reflect the current service.

The provider had failed to provide a safe and homely environment. They had failed to promote a culture of safety and to ensure the approach of staff was in line with the principles of dignity and respect. The provider had failed to ensure people were safeguarded from continued abuse and poor care. The provider had not recognised the impact on people from poor and abusive care and had not taken timely action to address these issues or to give people an active voice about their experience of care.

We observed staff providing care focused tasks which were not identified or challenged by the registered manager or other staff working at the service. We were not assured the culture of the service was focused upon improving the quality of care and outcomes of people living at the service.

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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager told us they had support from a regional manager and the provider, there was also a deputy manager who was also the clinical lead. Whilst when we raised concerns, the provider started to make improvements, leaders were not visible at every level. Staff were able to carry out poor and abusive care without the management team having effective systems to identify and act in people’s best interests.

The registered manager told us they carried out daily walkarounds, but these had failed to identify what we found on inspection. There had been a failure by the management team to identify and act on where risks were present or on poor care.

People did not always feel they could speak up and that their voice would be heard.

Staff told us, they could speak to the management about concerns. Relatives felt able to speak up and felt the provider listened. However, people were not encouraged to provide feedback and there were no effective mechanisms to ensure this happened.

We were not assured however people living at the service felt safe or able to speak up regarding the way they were treated and spoken to.

A whistleblowing policy was in place and staff were aware of the policy.

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.

We did not identify any issues with the recruitment practices of the provider and found there was a diverse workforce. There was an equality and diversity policy in place.

The provider did not have an open, proactive and positive culture towards safety. They did not listen to concerns about safety. Where safeguarding concerns had been raised by a person in the service the provider had failed to identify or address the concerns. Lessons were not learnt to continually identify and embed good practice.

The provider had not been effective in identifying the areas of improvement in the home environment to reduce the risk of people injuring themselves.

Accidents and incidents were documented however information was not clear or accurate with monitoring forms showing differing accounts of incidents to what was recorded in peoples care records. The clarity in the records needed to effectively detail, review and monitor the frequency of falls and incidents in the service was not there. This meant opportunities to learn lessons from incidents and take action were missed.

Whilst the provider carried out an annual satisfaction survey with relatives and people in the service, this had not been effective in identifying some people's concerns about the care and support they received.

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.

The registered manager told us they worked alongside the community, having summer fayres and festive activities. Health and social professionals did not raise concerns over how the provider engaged with them.

The provider told us they engaged with external professionals to make improvements to the home’s fixtures and fittings. However, we were not assured that priorities had been effectively assessed as concerns remained regarding fire safety and the safety of some aspects of the home environment.

The provider did not focus on continuous learning and improvement across the service. They did not encourage creative ways of delivering equality of experience, or outcomes and quality of life for people in the service. The lack of effective systems and management meant there was no drive to improve the safety of efficacy of the care and support being delivered. People continued to have poor experiences of care, with a lack of action to improve people’s outcomes. Risks were not identified or actioned to ensure people were safe, there was no focus on improving the safety for people and reducing the risk of injury.

The provider did not have oversight of how care was delivered. This meant opportunities to analyse and review accidents and incidents for themes and trends did not occur. Learning was therefore not identified and consequently not shared with staff. This meant improvements to the service and the care people received were not considered or implemented.