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 changed to 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 mission, purpose and values, centred around person-centred care and staff wellbeing. This information was available on the provider’s public website. These core values had been implemented by the registered manager and staff spoke positively about the changes made and the improvement in the culture of the service. Staff had quick reference guides to help them identify a closed culture and what they should do to prevent this. Staff told us, “The new [registered] manager has made a significant positive impact. They have been working hard to improve the service, support staff, provide more community activities and ensure individuals receive the best possible care. Their leadership has contributed to a more organised and supportive working environment."

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 registered manager, with the support of the management and staff team, had made significant improvements to the quality of the service. The registered manager was passionate about providing good care, and was kind, caring and supportive. The registered manager had liaised extensively with various professionals to ensure people received appropriate, evidence-based care. Various audits had been introduced to improve oversight of the service, and these were working in an effective way.

Staff, relatives and professionals spoke positively about the new registered manager, with feedback including, “[The registered manager] has much better oversight, things are handled in a much better way”, and “[The registered manager] is very friendly and approachable at any time.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager operated an open-door policy for people, relatives and staff. There were multiple ways people could provide feedback or speak up about any concerns they might have. The provider carried out surveys which were analysed and acted upon. There were QR codes in the service that staff, people, relatives and professionals could use to provide anonymous feedback. Staff had regular meetings and supervisions and were encouraged to raise any concerns as soon as they arose. One relative told us, “I can absolutely approach the registered manager, on the phone, mobile, and email, she is very communicative, and she will email me if they have any need to.”

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. Staff told us that jobs were allocated fairly now, under the new registered manager. Staff had no concerns about equality or discrimination within the work force. Staff told us, “Staff meetings are held every month and these meetings are very useful because they allow the whole team to share updates, discuss any concerns, review changes to policies, and make sure everyone is working consistently. They also help improve communication, teamwork, and the overall quality of care we provide."

The provider had implemented clear responsibilities, roles, and systems of accountability. There was a business continuity plan in place setting out actions to take in the event of various emergencies. Oversight of the service had improved, with multiple audits and quality assurance processes in place. These included spot checks, daily, weekly and monthly audits, provider audits and daily walk arounds. Audits identified issues, and actions were then implemented, completed and signed off. Although many positive changes had been implemented, these needed to become embedded. The service had a history of non-compliance with regulations, and the positive changes needed to be sustained and maintained.

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 registered manager liaised with multiple professionals and agencies to ensure all appropriate advice was obtained and a full and accurate assessment of people’s needs was carried out. The registered manager made referrals for people to other services to help support them and provide them with the best possible care. The provider shared learning between all the services within the organisation. The service was commencing an initiative using assistive technology to aid non-verbal communication and intended to feedback and share the results of this initiative with the local authority and other relevant bodies.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

Significant changes had been made throughout the service. There had been a sizeable focus on learning from the previous assessment findings and from the service’s own audits. The provider carried out ‘huddles’ with managers across the organisation, which focused on the improvement of key themes and where actions were discussed, agreed and implemented throughout the organisation. Weekly meetings were also held to discuss emerging topics and share good practice.

The provider carried out an extensive ‘lessons learnt’ exercise following the previous assessment, with learning being shared across the organisation. Actions were logged, completed, and reviewed to ensure progress was sustained.

The provider commissioned a ‘secret shopper’ audit of the service to gather independent feedback about the quality of support provided and to consider any improvements still needed.

The quality of the service had improved since our last assessment. One staff member told us, “There has been a tremendous improvement since the last visit, such as staffing, adequate and informed care plans, and improved activities for residents.”