Bradeney House Nursing & 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.

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 regulation 17 governance at the service.

This service scored 61 (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 and provider were open and honest during the assessment and shared the challenges they had overcome. The service worked with the local authority to make improvements to the care provided. Staff we spoke with told us they felt the service encouraged continuous improvement and the team worked well together. One staff member told us, ‘We work well as a team, at times morale can be low, but generally we get along together’.

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 provider was visible at the service daily and if not present on site was always contactable. The provider, who was also the registered manager of the service, showed support to staff and the management team. The provider had the skills required to manage the service effectively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff knew how to raise concerns outside the service if they needed to. One staff member told us, ‘I would raise a concern, if I didn’t feel listened to, I would speak to CQC or contact safeguarding.’ The provider promoted channels of speaking up. Staff we spoke with knew where to access information on speaking up.

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. Some staff we spoke with told us they didn’t always feel they could put ideas forward. One staff member told us, ‘I really think I could bring value to other areas of the home, but I don’t feel confident in raising’. Staff told us they worked well as a team and always helped and supported each other. The service supported staff who needed to work flexibly, and promoted a positive work, life balance.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Effective systems were not embedded into the service to ensure health and safety and medication concerns were identified. During our inspection we found no medication audits had been completed. We spoke with the registered manager who told us this was due to other demands of the service. This meant the concerns we identified during this inspection were not picked up and no action was taken. Health and safety checks were in place for equipment. However, these were not effective. We found a sensor mat for the floor had exposed frayed wires. Environmental and infection control audits failed to identify the concerns we found during this assessment. In people’s personal fridges in bedrooms we found out of date high risk foods. This could have caused people to become unwell or caused people to develop food poisoning. This lack of governance placed people at increased risk of harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information. However, actions were not always embedded into the service following complaints received. We found the provider and management team to be responsive to feedback received during this assessment. However, the management team had not identified the issues found during this assessment and did not have effective systems in place prior to our assessment. The provider completed an action plan during this assessment.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Where a complaint around people’s care was provided to the service, no learning was evidenced following the complaint. Concerns identified prior to our assessment had not been addressed. The registered manager was open to feedback and throughout the assessment showed willingness to improve.