Bethany House

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

This service scored 39 (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 mission, purpose and values, centred around person-centred care and staff wellbeing. This information was available on the provider’s public website. Despite this, staff spoke about morale being low, there being a divide amongst staff, and there being uncertainty about the management of the service. However, staff spoke positively about the interim manager who was in post at the time of the assessment and told us they had already observed improvements under this management. A piece of work for services to complete with staff entitled ‘Culture – Creating Understanding’ had not been completed by the management team of Bethany House alongside the staff team.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The location was not providing safe, effective and person-centred care. This had not been identified by the registered manager and the leaders of the service. The registered manager had failed to improve the quality of the service.

However, there was an interim manager in post at the time of our assessment. The interim manager had only been in post for 1 day when we started the assessment. During the course of the assessment, the interim manager worked hard to address the issues raised following our feedback, and was also pro-active in auditing the service, identifying issues, and putting plans in place to improve the service and the quality of the care provided. Staff spoke positively about the impact the interim manager had made in just a short period of time. The provider deployed various other senior managers to assist with the running of the service and acted swiftly to ensure the interim manager had the support required.

The registered manager had not always created a culture whereby people and staff felt they could speak up and their voice would be heard. Staff told us they did not always feel listened to by the registered manager or that their concerns would be acted upon. Feedback from staff included, “If I see anything I don't like I will report it to management - previously with the registered manager this wasn't always acted upon; it seems different now.”

However, the provider had identified this issue and taken steps to support staff to speak up. The provider had held sessions with groups of staff to support them in their right to speak up freely.

Staff did not always feel they were treated fairly and equitably. Staff spoke about a divide between the staff team and an unfair allocation of tasks under the registered manager. Staff feedback included, “Previously it was very unfair, and the jobs allocated were not split equally between all staff members.”

Staff told us flexible working hours were not always adhered to, and changes in shift patterns to attend appointments had not been accommodated under the registered manager. Staff told us these issues had improved under the interim manager.

The provider did not have effective governance arrangements in place. Registered manager and provider oversight had not identified or resolved the issues found during the assessment. For example, audits were completed monthly, and they had reviewed the support plans we reviewed during the assessment. The audits were ineffective because they had failed to establish the issues we identified during this assessment. Provider oversight was based on inaccurate information and had also failed to identify the shortfalls in the quality of the service. Systems were not in place to effectively and safely manage risk, to sustain good quality care, and improve outcomes for people. We found people’s quality of life had deteriorated, along with the quality of the service generally.

The provider did respond well to impromptu changes in the management situation at the service and implemented contingency plans swiftly to sustain the running of the location. Similarly, when issues were identified, members of the senior management team attended the service to assist and ensure the smooth running of the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. Information from other services was not always obtained or recorded within people’s support plans, resulting in potentially key information about people’s needs being missing. For example, outcomes from referrals and assessments were not always incorporated into people’s support plans.

Systems were in place to share learning throughout the organisation, with managers’ ‘huddles’ taking place which provided opportunities to discuss topics and share good practice.

Following our assessment feedback, the provider liaised with other services to gather relevant information and seek advice and support where needed.

The provider did not focus on continuous learning, innovation and improvement across the location. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

There was not a robust, clear and consistent system in place to record incidents and accidents which meant effective oversight could not take place. There was no evidence of any analysis of data to look for trends and themes, to support continuous learning and improvement.

The location had a history of non-compliance, and this was the third consecutive occasion the location had been found to be in breach of regulatory requirements. The provider failed to improve following the previous inspections and failed to attain and sustain a ‘good’ rating. We found the quality of the service had deteriorated at this assessment.