Bywell House Care 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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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. The registered manager had provided staff with additional training to increase their knowledge on supporting people living with dementia. A health professional told us, “There is an improved understanding by the care staff of the advice given. Advice is acted upon.” We observed the registered manager’s open-door policy with staff, people and their relatives freely entering the office. The registered manager told us, “My door is always open, I never close it.” They further commented, “I like to be on the floor and know what's going on.” A relative said, “I get updated and pop in and see the manager when I am there. I have seen the care plan and I've also had 2 discussions with the DoLS team where we discussed [person’s] care. I am kept up to date.” Staff meeting minutes demonstrated inclusivity and gave staff a voice. Feedback surveys were circulated to staff, people and their relatives, results were shared amongst the staff team for wider learning.

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. Our observations confirmed the registered manager was present in the service, engaging with people and staff. The registered manager clearly knew people well and people knew them too. At the time of our inspection, the manager had only recently been registered with CQC although they had worked within the service for around 18 months. This had enabled them to work with people and staff and understand challenges. A staff member said, “[Registered manager] is helpful and even though they are a new manager to us, the way [registered manager] talks and tries to help is better.” A health care professional told us, “[Registered manager] is very helpful and knowledgeable and knows residents well.” Staff and the registered manager spoke highly of the support they received from the provider and other members of the head office team.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had a policy to support them to speak up if they had any concerns. Staff told us they were confident to speak up and gave examples where they had done so in the past. They told us they were listened to and suggestions were actioned. A staff member said, “If I come up with any idea they listen and work on it. Or if they cannot, they explain why.” Another said, “[Registered manager] is very private when staff want to speak with them, they will close the door and no one will know what's gone on.” The registered manager told us, “We are a team, they are not afraid to come and ask me. They can call me any time, day or night.”

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. Flexible working arrangements were in place for cultural and religious observances, and wellbeing initiatives included team-building events and celebration of festivals. Staff told us how they had made suggestions to celebrate cultures from around the world including menu suggestions and dance performances from different countries. Some staff required specific working hours to suit their childcare arrangements and told us the registered manager prioritised this when planning their shift patterns.

The provider was embedding new responsibilities, roles, systems of accountability and governance. The registered manager had been in post for just over a month and was in the process of updating various checks and audits. Governance systems were in place but not fully embedded. Audits were completed for medicines, IPC and the environment, with prompt action on findings. However, some areas required additional review, including MCA documentation and integration of nutritional screening tools into digital systems. The registered manager was working through legacy issues whilst prioritising wellbeing and safety. The registered manager was in the process of training and empowering senior members of the care team to assist with audits, this included taking some responsibility with care staff supervision. The provider visited the service monthly and undertook their own review of quality, where they had identified areas for upgrade, these had been completed or were scheduled in.

The provider 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. We observed collaborative working relationships with district nurses, community matrons and mental health teams. A health care professional commented, “There has been a noticeable change in residents. They are happier, more engaging and seem to be smiling more.” The service worked with other care homes in the area to enable mutual visiting arrangements as some people living at Bywell House had loved ones living in other care settings. The registered manager had contingency plans agreed with neighbouring homes in the event of an emergency. Weather permitting, people frequently went out for walks, coffee and ice cream with staff or their families.

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 had a commitment to ensure all staff received support and training to develop them in their roles. They had carefully researched and sourced a new training provider. A staff member commented on this and said, “Training is more measured now. I have learned more online than I ever used to.” The registered manager shared with us how they were developing their own knowledge and experience. There had been changes within the environment, the registered manager told us how they had researched calming colours for people living with dementia and added new lighting and pictures. They said how this had made a big difference to people’s mood and reduced incidents of anxiety.