Bishop's Cleeve 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 requires improvement. At this assessment the rating has remained 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 provider was in breach of legal regulation in relation to governance.

This service scored 46 (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’s vision, strategy and culture were not always embedded within the staff team, and not all staff felt the provider was working in line with their vision, strategy and culture.

Staff gave mixed feedback on training provision, support from the provider and standard of work/life balance. There was not always an open or positive culture. People using the service, relatives and staff explained they did not always feel their needs were considered in the governance of the service. People told us complaints and concerns were not always addressed to their satisfaction. They did not feel leaders were visible and they did not have opportunities to share their opinions of the service. There were forums for people to give feedback, including meetings. However, some people felt these were not effective. People and relatives thought staff were kind, although their needs were not always met in a person-centred way.

Staff felt leaders were not always accessible or responsive. Some staff told us they did not think there was a supportive atmosphere. Their comments included, “I don’t feel comfortable approaching management team. I don't feel issues and concerns are addressed” and “I don’t feel wanted anymore, like they don’t want me here.”

Leaders did not always have the skills, knowledge and experience to lead effectively.

At the time of the inspection, the service was being supported by the acting manager who was stepping up during the period of recruitment for a new manager. The provider had not considered additional support which might be required during the transition period. Some staff told us they did not feel confident approaching the acting manager as they felt they would not be listened to or treated fairly, although our observations did not support this feedback. However, we found the acting manager to be open, honest and compassionate and responsive to our feedback.

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

Staff told us they felt they could not voice their opinions safely without fear of being reprimanded by managers. We saw evidence of past incidents where investigations into staff struggling with their workload were demoted rather than supported with reasonable adjustments or re-training. Staff told us the provider did not listen when they reported being chronically short staffed.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff working via sponsorship visas told us they felt the provider did not always treat them fairly. They told us the provider had changed some policies which made it harder for them to continue with their sponsorship. Staff told us they felt this was not equitable and only applied to newly sponsored staff.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider and managers had failed to implement, embed and sustain improvements needed for effective governance. The provider had failed across multiple assessments to ensure safe management of medicines, falls management and good dementia care. Audits and governance tools in place did not identify concerns identified during the assessment, for example, the lack of investigations into accidents and incidents and the lack of actions after high numbers of wounds and falls were identified. The service had multiple managers since our last assessment, the lack of consistency led to a deterioration in sustainability. While there were senior managers and quality managers in place, they did not ensure timely support while a new manager was being recruited. This placed the service at risk, and therefore the people living there at risk. We found this had impacted people’s mental wellbeing and physical health, as well as people’s access to equitable treatment and choice.

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.

The provider shared information appropriately with external professionals. The service enjoyed a positive reputation in the local community and invited local residents to attend the church service and coffee mornings. Relatives told us, “[Person] had a few problems and the GP said to have respite care. It just moved on from respite to permanent. We looked at quite a few [services] and this home won.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not understand their responsibilities to focus on the quality of life and safety of people living at the service. The provider had not assured us people were receiving care and support in line with people’s expectations. People were not always kept safe, given independence, supported with risk taking or involved in their own care. This meant people had decisions made for them, without adequate safeguards, such as multi-disciplinary team meetings or assessments to support decisions being made.