Archived: Bethany Lodge

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• 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

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 inspection 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 service was in breach of legal regulation in relation to good governance at the service.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

CQC inspect learning disability services in an enhanced way following the principles shared in the CQC Guidance of Right Care, Right Support and Right Culture in May 2022. It is required all services providing care to people with Learning disabilities design and deliver care in line with these principles. We found the care provided to service users in Bethany Lodge did not reflect the best practice guidance in these principles, and this meant service users were not receiving care reflected individual’s complex needs. The delivery of care did not make sufficient provision for people’s autism and complex needs, meaning that peoples experienced uncertainty and anxiety on a daily basis.

There was not an open and transparent culture in the service. Incidents were not reported to the relevant authorities, including CQC and staff did not feel they could raise concerns without fear of reprisal from the management team.

The provider had failed to identify the manager lacked an approach which supported and encouraged challenge and learning, and failed to enable external scrutiny.

The provider had not taken reasonable steps to ensure governance and management of the service was effective and carried out by competent staff. There has not been a registered manager in post since 3 June 2024, and the lack of transparency in subsequent managers reporting incidents and taking actions to protect people and staff has led to a culture which is not open and transparent.

The provider and manager did not fully understand the context in which they delivered care, treatment and support. Where concerns were identified by visiting professionals the understanding of what actions to prioritise and take was not always evident, and this had led to people continuing to be placed at risk of poor or unsafe care.

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

We were not assured people living at the service were able to speak up regarding the way they were cared for.

A whistleblowing policy was in place and staff were aware of the policy however did not always feel supported by the provider or management to raise concerns. We received whistle blowing concerns from staff both before and during the inspection raising concerns over the treatment of and openness around incidents and concerns in the service, by the management team.

The provider did not have effective systems to ensure the effective integration of staff. This was evidenced by a lack of oversight and control of staff allocation and a lack of assurances over agency staff background, skills and abilities. We were not assured there was adequate oversight by the provider to encourage workforce equality, diversity and inclusion. The provider could not demonstrate how they had confidence in how staff delivered care at the service.

The provider did not have sufficient oversight arrangements to ensure there were adequate systems and processes in place to assess, monitor and improve the quality and safety of the care and support delivered to service users. This meant people have been placed at risk of not receiving planned care and have been exposed to the risk of unnecessary harm.

The provider did not have an open, proactive and positive culture towards safety. Systems and processes did not identify the actions needed to be taken following feedback from inspectors. Issues around the management of risks remained throughout all 4 days of inspection visits. Whilst the provider had given verbal assurances actions would be taken, actions taken failed to provide us with adequate assurances.
The provider had not been effective in identifying the areas of improvement in the home environment to reduce the risk of people injuring themselves.

The provider continued to place people at risk of physical and emotional harm due to continued failures in leadership and oversight.

Whilst the provider had positively engaged with health and social care partners once issues had been raised, the continued identification of risks by visiting professionals raised concerns over the effectiveness of prioritising and taking pro-active actions to keep people safe.

People’s experiences at Bethany Lodge did not reflect partnerships with the local community. Support and activities for some people was provided in isolation limiting peoples opportunities for expanding and maximising on their skills and experiences. The approaches of the staff failed to promote active involvement from people, one person was not encouraged to leave their room for significant periods of the day with their allocated staff sitting outside the person’s room with no interaction given to the individual. Staff and the manager could not provide information on activities or approaches used to encourage the person out of their room. We raised concerns at the lack of action to address the isolation and experiences for this person. Another person’s day consisted of repeated trips to McDonalds with drives out offering no opportunity for positive engagement with the local community. A relative told us their loved one “is mentally deprived of stimulation and activities and good human contact.”

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

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