Bybrook House Nursing 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 good. At this assessment the rating has changed to requires improvement. This meant the governance systems were not effective in supporting the provider to assess, monitor and mitigate risks.

The service was in breach of legal regulation in relation to good governance.

This service scored 62 (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.

Staff we spoke with all said they really enjoyed their jobs. They said Bybrook House was a nice place to work, and they all said they provided good care. One member of staff said, “The care standard is good. Any staff who come and are not good, they get found out. We pick things up fairly quickly.” The registered manager told us they regularly carried out observations of staff practice to make sure staff were working to the expected standards and values. If staff were not following expected standards, this was addressed immediately.

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.

There was a registered manager in post who had been at the service for many years. They knew people and staff well. People told us they knew who to approach to share any concerns and they felt the service was well managed. One person said, “I think this place has a nice atmosphere, that comes from the top. The manager is good; the nurses are good. I think the service is well managed.”

Staff said the registered manager was approachable and well respected amongst the staff team. Comments from the staff about the registered manager included, “I think it is well-led, [registered manager] is very approachable, their door is always open” and “[registered manager] is good, it is a nice place to work. The nurses are also lovely, I feel comfortable here.”

The provider supported the service with regular visits from head office staff. The registered manager told us they felt supported in their role and always had support available from the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were provided with training on speaking up and knew what to do if they had any concerns. Staff said they would initially raise concerns internally, but they knew where to go if they wanted to share anything outside of the service.

There had been no incidents which came under the requirement of duty of candour.

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 had training on equality and diversity which was regularly refreshed. The registered manager told us staff from all backgrounds and nationalities were welcomed at the service and equal opportunities applied to all. Celebrations of different cultures had taken place which involved sharing food from different countries and talking about differences in cultures.

Staff confirmed there was no discrimination and everyone was welcomed and included.

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

Checks on quality and safety for some areas had not identified shortfalls found during this assessment. Health and safety checks completed the month prior to this assessment had not identified that window restrictors were either not in place or were faulty. Leaders told us staff had tampered with window restrictors to open windows wide. However, governance checks had not identified these actions taken by staff which placed people at risk of harm. The provider took immediate action to address the shortfalls found and make sure window restrictors were being used safely. Medicines were being checked monthly. However, all of the recent checks completed had not identified the shortfalls found at this assessment.

Other quality checks were working well to monitor and improve quality and safety. For example, there were regular care plan audits, pressure area care audits and kitchen audits. Actions were identified and the registered manager had recorded when they were completed.

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.

People’s health needs were being met as staff liaised with a range of stakeholders. There was a weekly GP visit which people appreciated. Staff collaborated with professionals from health and social care agencies.

Healthcare professionals contacted did not share any concerns about the service. One professional said staff were responsive and listened to their advice. They said there was good teamwork and the service was well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager told us they regularly met with other managers working for the provider. Learning was discussed and updates shared on any new ways of working or changes in legislation. The registered manager shared some examples of new systems they wanted to implement. For example, they wanted to add photos of exactly how to use slings and hoists to people’s care records. This would support written guidance and be a visual prompt for staff. They also shared the provider was looking to respond to people, relative and stakeholder feedback by making the car park bigger. This would enhance the visitor experience at the service.