Briarfield

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 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 good governance.

This service scored 50 (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 did not always ensure its vision, values and culture were consistently reflected in people's experiences and outcomes. Systems and processes to understand and monitor people's experiences were not fully embedded. As a result, the provider could not always demonstrate that people were fully supported to achieve the outcomes that mattered to them.
The provider accepted our feedback in this area and told us they had begun making improvements to these processes.
However, the provider had a shared vision, strategy and culture based on promoting people's wellbeing. The service's vision, mission and values were clearly displayed within the home, and staff were able to describe and understand them. This helped provide a shared sense of purpose and direction for those working within the service.
 

Leaders did not always have the oversight or systems required to consistently identify, recognise or escalate concerns within the service. Gaps in internal processes meant risks were not always reliably identified or acted upon. Although leaders created an inclusive culture, their understanding of the service did not always translate into effective governance and assurance arrangements. This limited their ability to maintain consistent oversight of quality and safety.
Leaders were visible within the service and demonstrated a good understanding of the needs of people living in the home. One staff member told us, "[Registered manager] is visible. If you ever need [registered manager], you go and get [them]."
However, some staff told us the registered manager was managing significant demands and would benefit from additional support. One staff member said, "[Registered manager] has a lot of things to deal with. [They're] juggling so much and doesn't get the support [they] need and it's so busy in that office. People and service users are in there all day and [registered manager] gets no time to do [their] job." Staff told us the management structure was limited and would benefit from additional leadership capacity, such as team leaders or a deputy manager.
Throughout the assessment, we identified areas where greater provider oversight was required to ensure governance arrangements were effective. The provider was responsive to feedback and took action during the assessment to strengthen management support within the service.
 

Staff did not always feel able to speak up with confidence that their views and concerns would be acted upon.

Staff did not always feel comfortable or supported to raise concerns. Although systems were in place to encourage feedback, some staff lacked confidence that concerns would be addressed appropriately or result in meaningful action. Some staff told us they felt issues needed to be escalated beyond the service before improvements were made. This limited the provider's ability to demonstrate an open and transparent culture where people and staff felt empowered to speak up.
 

The provider did not always promote an inclusive and fair culture for staff. Systems were not always effective in ensuring staff experienced equity and consistency in relation to working arrangements and support.
Staff experiences of equality, diversity and inclusion were varied. While some staff felt they were treated fairly and valued the training provided, others reported inconsistencies in how staff were supported, particularly in relation to shift patterns and flexible working arrangements. Some staff felt flexible working arrangements were not always applied consistently and had a greater impact on part-time staff.
The registered manager told us they would seek to adjust staff hours and working patterns where possible to meet individual needs.
Some staff did not always feel recognised for their contribution. One staff member told us, "I used to do extra shifts to help out, but I won't now as it's not appreciated and I never get thanked." However, staff reported receiving effective equality, diversity and inclusion training and spoke positively about the opportunities available to develop their understanding. One staff member told us, "Training has been good, we've done courses on equality and diversity, dignity and respect."
 

The provider did not have effective systems of governance, oversight and accountability. Quality assurance processes had failed to identify and address a range of concerns relating to people's safety, care and treatment, the environment and compliance with legal requirements. As a result, leaders could not be assured risks were identified, monitored and acted upon, and people were not always protected from avoidable harm.
Governance systems and management oversight were not effective. Although the registered manager told us daily walkarounds were undertaken, these were not documented. Audits across key areas, including care planning, medicines, water safety, fire safety, infection prevention and control and the MCA, had not identified concerns found during the assessment.
Systems had failed to identify gaps in people's care plans, outcomes, risk assessments and MCA documentation. Oversight processes had not highlighted concerns relating to medicines storage, environmental safety, infection prevention and control, incident recording or behavioural support. Environmental audits had also failed to identify issues including poorly maintained areas of the home, unsafe outdoor spaces, exposed pipework and hazards within the environment.
Infection prevention and control audits were undertaken infrequently and had not identified concerns observed during the assessment. Governance systems had also failed to ensure people's rights under the MCA were consistently upheld, including identifying missing mental capacity assessments and deficiencies in best-interest decision making.
These concerns demonstrated widespread and sustained weaknesses in governance arrangements.
 

The provider understood the importance of working in partnership with other organisations to help ensure people received coordinated care and support. Staff worked collaboratively with health and social care professionals and shared relevant information when needed to support people's wellbeing and continuity of care.
Professionals spoke positively about their relationships with the service. One professional told us, “I found them to be very accommodating, I phone and arrange a visit, my emails are answered quickly by manager’s name. For my visit they are prepared. The home is very welcoming and homely.” There was evidence of effective joint working with a range of health and social care professionals, including referrals being made and healthcare support being accessed when required. This helped ensure people received the support and treatment they needed in a timely way.
 

The provider did not always demonstrate a culture of continuous learning, improvement and innovation. Opportunities to identify, record and learn from events were sometimes missed, which limited the provider's ability to drive and sustain improvements.
There was some evidence of learning within the service, and staff told us they were informed about some incidents and encouraged to learn from them. However, some incidents were not consistently recognised or recorded, meaning learning and service improvements could not always be evidenced.
The provider had worked with commissioning bodies to improve the quality of care and documentation. Following the assessment, leaders shared service improvement plans which demonstrated action was being taken to address areas requiring improvement. However, further work was needed to demonstrate consistent and sustained improvement across the service.