Bright Meadows

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 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 understood their responsibility to provide safe and effective person-centred care to people, in line with the provider’s vision and values for the service. The provider’s policies, along with the statement of purpose, detailed their vision and values and how these would be achieved.

The provider’s policies and procedures were regularly reviewed, to ensure they remained up to date and in line with current best practice. Each month the provider focussed on a specific policy, which was displayed on the staff noticeboard. This helped refresh staff knowledge.

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 service had a registered manager who had been in post since 2022. At the time of our assessment, the registered manager was off sick, with the deputy manager taking responsibility for the day to day running of the home, supported by a manager from another of the provider’s care home’s.

Overall, people and relatives we spoke with knew the management team and said they felt comfortable speaking to them and if needed raising concerns. People also stated the home was well run and they would recommend it to others. Comments included, “I do know the manager and I feel comfortable in talking to her or any of the carers” and “I would recommend this home as it’s comfortable and secure with staff around to assist at all times. I like the way that they keep my son informed of my health and of any changes too.”

Staff stated they felt supported, especially by the deputy manager, who they interacted with regularly. One staff member told us, “Our deputy is very approachable, listens to our concerns. Sometimes I don’t know what to do and they will advise.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Information on how to speak up and/or report concerns was easily accessible.

A detailed speaking up / whistle-blowing policy was in place. This had been regularly reviewed. Posters explaining how people and staff could report concerns were on display within the home. These included details of a dedicated confidential whistle-blowing phone line, along with suggestions of other avenues for reporting such as the home manager, regional manager or externally via CQC. The home also had a speak up guardian, who could support staff to raise concerns and/or act on their behalf. A staff member told us, “There’s a whistle-blowing process here. It is signposted in reception, on each unit and in the staff room.”

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.

The provider’s equality and diversity policy referenced the latest guidance and legislation and included sections which covered, discrimination of employees, sexual harassment, disabilities, immigration status and neurodiversity. The policy also referenced people’s protected characteristics and how these would be respected.

The provider had an employee assistance programme, which included free and confidential access to counselling and wellbeing support, alongside a range of other benefits and services.

The programme’s wellbeing platform provided information on fitness, nutrition, meditation, and access to e-learning courses on wellbeing. Although posters advertising the employee assistance programme were displayed in reception, staff knowledge of the programme was limited. We fed this back to the provider who agreed to promote this during staff meetings.

The provider had an employee of the month award scheme. Voting slips and box to deposit these, was located in the reception area, along with a sign asking people to nominate their employee of the month.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, governance processes had not identified all of the issues we noted during the assessment.

A number of governance processes were in place, including daily flash meetings, daily walk rounds and the provider’s audit programme.

Auditing was completed in line with the provider’s governance schedule. This detailed the daily, weekly, monthly and quarterly checks which should be completed. An electronic system was used for the completion of audits. The system could be accessed by the provider and the regional manager who supported the home, to aid oversight. The provider reviewed completed audits and outcomes with management on a weekly basis. Provider level auditing was also completed, to supplement those completed internally by management. Although recent audits had noted issues with monitoring charts, conflicting information in care plans and how topical medicines were recorded after being applied, not all of the issues with medicines management we found had been identified.

During daily walk rounds, a member of management reviewed the environment, checked cleanliness, ensured staff were dressed appropriately, looked at a selection of records and monitoring charts and observed the provision of care including the mealtime experience. Where any issues had been noted, actions were generated and shared with relevant staff members. A second walk round was completed in the afternoon, to follow up on any actions and ensure they had been 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.

The provider worked closely with the local authority and their quality team, to ensure they were meeting expected standards. Following an assessment by the local authority in November 2024, the home had been rated good overall, though some areas of improvement were identified. The provider had worked with the local authority to make the necessary improvements.

The provider was involved in the Pressure Ulcer Collaborative. This was an initiative which included various health and care services across the borough and aimed to decrease the percentage of pressure ulcers in people using services. This was to be achieved through a multidisciplinary approach including staff training, skin inspections and promoting and supporting people to remain mobile.

The provider had formed links with a number of community groups and organisations, including a local church, who held services within the home, which people and relatives could attend.

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.

Individual improvement plans had been completed following any assessment or monitoring process carried out by external organisations such as CQC or the local authority. These sat alongside the provider’s own service improvement plan, which contained actions generated from internal audit and governance processes.

A process was used to identify any learning from incidents. The process involved looking at each incident or accident, trying to identify the cause, reviewing how the incident had been dealt with, what the staff and/or provider had done well, and what could have been done better, and considering any lessons learned moving forwards. These were shared in daily flash meetings and subsequently cascaded to staff.

Views about care provision and any areas for improvement had been sought through surveys. The provider used a ‘You said... We did...’ board to feedback changes made, based on people or relative’s responses. Not all issues or suggestions from the last survey had been included on this board, though were part of the provider’s service improvement plan. We discussed with the provider the importance of ensuring a robust feedback loop was in place, so people and relatives knew they had been listened to, and action had been taken.