Betsy Clara 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 good. At this assessment the rating has changed 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 service was in breach of legal regulation in relation to governance at the service.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. However, we received mixed feedback from staff about the culture of the service.

Some staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Other staff told us, they did not feel empowered to raise concerns and said they did not always feel listened to. Comments included, “They are not very supportive in relation to challenging residents, sometimes we get injured when people are challenging such as bites or being spat at. Managers laugh when we report it and don’t offer any emotional support”; “I feel able to speak up, and I have always spoken up, my concerns are always resolved” and “The culture is not open; concerns are ignored.” Some staff had reported some negative feedback in the staff survey. The provider had been exploring the feedback and had enlisted the human resources team to meet with staff to gain further information and insight.

The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The management team knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with the registered manager, a deputy manager and a clinical lead nurse. Nurses provided clinical support to people. The service also employed senior care workers and care workers to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by a compliance manager who visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider. The registered manager met daily with heads of departments to ensure key messages about people were shared in a timely way. Daily handover meetings were held so staff had up to date information about the people they were supporting. Some staff told us the management team were supportive and approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly.

Complaints processes were available. People knew who to talk with if they had concerns or complaints. This included reporting their concerns to staff, reception staff or the registered manager. We observed people visiting the registered manager in their office and were supported appropriately.

Relatives knew who the registered manager was. Comments included, “[Registered manager] has been brilliant. Her office is always open.”; “I know who the home manager is” and “I know the manager by face but not by name, I have no doubt she’d deal with any problems.”

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. However, feedback from staff showed this did not always work in practice.

Some staff told us any issues could be discussed openly at staff meetings or during supervision. However, some staff reported concerns. The provider had processes in place to encourage an inclusive culture. The registered manager told us they had an open-door policy. Some felt well supported and some did not. Staff told us about the support they had been given in their roles. We received mixed feedback from staff. Comments included, “There is favouritism and bullying across shifts and management levels. Staff fear speaking up; several colleagues have left due to toxicity”; “I do not feel safe speaking to [registered manager]. There is bullying, cliques, and favouritism among staff, especially involving senior staff. Carers are made to feel they should not have an opinion”; “I feel unsupported, bullied, and I now avoid overtime shifts. Staff fear retaliation if they speak up or contact CQC” and “Management support is good; problems are dealt with quickly. I am happy in my work. I love looking after the residents.” After the assessment visit we continued to receive anonymous negative feedback about the service. We fed these concerns back to the management team. The nominated individual for the provider allocated resources outside of the direct management team to investigate the information.

The workforce was diverse, and support was in place for staff. The registered manager ensured staff with protected characteristics were supported with any reasonable adjustments if required. For example, altering shifts and working times to accommodate childcare arrangements and religious needs.

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, or share this securely with others when appropriate. The provider had systems in place to check the quality of the service. Audits had been carried out. There were monthly audits of infection control, care plans, medicines, falls and wounds, incidents and accidents, health and safety, fire, nutrition and weights and complaints. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, the monthly care plan audits had not highlighted issues with mental capacity assessments, there was conflicting information in some audits about checks of gas boilers. Actions from audits had been recorded and the management team told us these had been addressed. There had been a lack of clinical and management oversight of constipation risks relating to people as systems were not in place to review bowel charts regularly. This had led to people not receiving medicines and help in a timely manner to relieve constipation. After we raised this during the assessment, the registered manager put in place a process to ensure nursing staff working the night shift would run a report on constipation from the electronic care planning system to identify anyone that my need support with constipation (from high fibre food or through the use of any prescribed medicines). The provider had oversight of the audits and checks within the service through a digital platform and through regular communication with the registered manager.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. The provider had displayed their last inspection rating on their website and within the building.

The management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with GPs. The registered manager told us about partnerships with schools/colleges that had been set up. Young people interested in a career within health and social care had completed placements at the service to enable them to gain experience and qualifications. We saw that this had a positive impact on the young people. One young person had written to the registered manager praising the service and asking to be considered for work when they reached 18 years old.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager and nominated individual for the provider told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions. The nominated individual for the provider told us, “The feedback was fair and balanced, and we will take an opportunity to make improvements. I am thinking of asking [human resources] to come to the service to meet with staff due to the feedback about culture and bullying.” After the assessment they confirmed this action had taken place. The registered manager told us improvements were being made to continence care so it would be clearer in each person’s care plan what is normal for them and what the escalation routes are (if people had not opened their bowels).