Bankfield House 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. 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 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 not yet embedded a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The registered manager shared their vision for the home, which focused on placing people at the centre of their care and on empowering and developing the staff team. There had been several changes since our last inspection, including the recruitment of new staff, a programme of refurbishment, and strengthened oversight and governance processes aimed at improving quality. However, we continued to find areas of shortfall across the service, including with staff practice and record keeping, meaning that further action was needed to realise the registered manager’s vision. Some areas of concern identified at our last inspection had not yet been fully addressed.

Feedback from people, relatives and staff indicated that improvements were being made. People were generally happy living at the home, relatives felt their family members were safe and well cared for, and staff said they felt supported in their roles.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always have the skills, knowledge, and experience to lead effectively.

Further work was needed to ensure good practice became embedded and that systems and checks of the safety of the service were used effectively by all members of the management team. It was not always evident the management team had an accurate and up to date overview of the needs of people and the running of the service.

Feedback about the registered manager was positive. People told us they knew the registered manager and that they were visible within the home. One person told us, “[Registered manager] is absolutely wonderful. They will do anything they can to help me, and I wouldn’t swap them for anything.”

A relative who lived some distance from the home said communication was good and told us, “They send me photographs of [family member] joining in with activities.”

The provider fostered a positive culture where people felt able to speak up and were confident their views would be heard.

People and their families told us they could raise concerns and were confident that any complaints would be addressed. Where concerns had been raised, the registered manager investigated them, took appropriate action, and provided feedback to the person involved. One relative told us, “[Family member] has built good relationships with the manager and the staff. The manager is brilliant. Getting through on the phone can be difficult sometimes, but they have been a great support and helped me with paperwork and other things as well. The only concern I had was when a carer was feeding a resident in an inappropriate way. I mentioned it to [registered manager], and I haven’t seen that carer since.” A ‘You said, we did’ board in the reception area showed people and families what actions had been taken in response to feedback.

Staff told us they felt able to raise concerns. Appropriate policies and procedures were in place, including whistleblowing processes, to support staff to speak up where needed.

The provider valued diversity within their workforce and worked to promote an inclusive and fair culture by supporting equality and equity for staff.

The registered manager told us they took a flexible approach to supporting the staff team. Staff said they felt well treated and described a positive sense of teamwork within the service.

The provider did not always have clear responsibilities, roles, systems of accountability, or effective governance processes. They did not consistently act on the best available information about risk, performance, and outcomes, or share this appropriately when needed.

There was an improving picture of oversight and governance. The registered manager had introduced a range of audits and checks within the home. However, these were not always effective in identifying the concerns we found during this assessment.

For example, care plan audits were in place and had identified some areas for improvement in person-centred care. However, they did not identify inconsistencies in recorded information, including details relating to people’s moving and handling needs, equipment requirements, and dietary needs. Although care plans were reviewed regularly, they did not always provide an accurate and up-to-date reflection of people’s needs. Information known by staff and the registered manager about people’s required care was not always clearly recorded in care plans.

Regular medicines audits were also carried out; however, these did not effectively identify where records were inconsistent, inaccurate, or lacked sufficient detail, or where the provider’s policies had not been followed. It was not always evident that staff administering medicines understood their responsibility to escalate concerns, such as missing signatures or repeated missed doses, so that appropriate action could be taken.

Competency checks of staff moving and handling practices had been completed, but these had not identified some of the significant shortfalls we observed in practice. Following the inspection, the registered manager took action to complete further competency assessments and had plans to extend these checks to other areas of care.

The provider understood their duty to collaborate and work in partnership, so that services worked more seamlessly for people. They shared information and learning with partners and worked collaboratively to support improvement.

The registered manager and activity coordinator spoke about the relationships they were developing within the local community and plans to strengthen these further. However, additional work was needed to build on these partnerships and ensure people had consistent and meaningful access to community opportunities.

The provider did not always focus on continuous learning 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 and effective practice.

Further work was needed to ensure the learning and improvement continued to be embedded into practice. For example, we feed back some concerns about the moving and handling process on the first day of our visit and continued to find shortfalls in how people were supported in this area throughout the inspection.

The registered manager had processes in place to ensure lessons were learned following incidents, including the use of root cause analysis to understand what had happened. The registered manager also embraced the use of technology to support improvements. For example, they identified that some people were moving sensor mats intended to alert staff to movement for those at high risk of falls. In response, they arranged for bed sensor alarms to be introduced.

Feedback from people and their families indicated that improvements were being made. One relative told us, “I have seen the improvements and when I go away, I have great peace of mind that [family member] is safe and being well looked after.”