Bromford Lane Care Centre

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 inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of 2 legal regulations in relation to governance at the service and fit and proper persons employed.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not demonstrate they understood the challenges and the needs of people and their communities.

In their failure to take consistent, timely action in response to risks and concerns, the provider had not prioritised safe and high-quality care or the promotion of a culture focused on learning and improvement.

Staff meetings, supervisions and spot checks were not robust in identifying where additional staff support was required to help drive improvements in the service.

Reviews of people’s care plans had not ensured a fully inclusive and collaborative process of care plan development.

The provider’s staff training provision required improvement to better reflect people’s individual needs and so further promote equality and diversity.

Risk assessment and care planning processes had not always resulted in care plans which reflected and acknowledged people’s diverse needs.

Whilst the registered manager told us they welcomed and supported an open culture some staff continued to feedback to us highlighted that the culture within the service was not always open and supportive. Staff told us they were confident in recognising poor practice and knew how to report this. Most said they felt it would be acted on by management. People and relatives told us overall staff were kind and compassionate.

We saw that a monthly newsletter was produced to share information on what took place in the service and other information of interest including how to complain.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Although the registered manager was present within the service, there was a continued failure to demonstrate they led by example with promoting inclusive behaviours. During our assessment the registered manager retired from the service, and 2 new management and regional support teams came to support the service during the assessment period. The provider and management teams engaged with the onsite visits and feedback and responded to our requests for information. However, gathering some information was challenging at times due the registered manager leaving the service during the assessment. The management and provider were receptive, overall, to our feedback and took some steps to immediately improve safety in the service following our feedback based upon our findings.

The provider told us they visited the service to provide support and to carry out audits. However, these audits were not robust as some issues we found had not been identified by the audits. Where the provider’s audits had identified shortfalls in the service there was little evidence that the actions identified had been completed. There was a lack of provider oversight and actions in relation to the issues and priorities for the quality and safety of people’s care identified in these audits. The provider did not demonstrate how they ensured the management team were supported to ensure actions were met in suitable timeframe ensuring people’s safety and wellbeing.

The registered manager had delegated a variety of tasks and audits to be completed by other members of the team. However, they failed to have suitable oversight of the completion and outcomes of these, including the completion of actions identified in a timely way. This demonstrated a failure of their leadership.

The registered manager had delegated the completion of supervisions with staff to heads of departments. However, these did not consistently ensure staff had the necessary skills and knowledge, were competent in their roles and had the opportunity to identify any additional support or development needs they may have.

Most people and their relatives knew who the registered manager was.

Overall, people and relatives spoke positively about the management team who they told us were approachable.

Some staff told us they felt supported and valued by the management team and understood their roles and responsibilities. Other staff told us they felt less supported but spoke positively about the recent management and regional support teams who had come into the service and the changes they had already implemented.

People did not always feel they could speak up and that their voice would be heard.

The provider had failed to adopt an inclusive approach in gathering feedback from people to give them the opportunity to share any concerns they may have.

Most staff told us they could raise concerns with the management at any time, but others continued to tell us they felt unable to speak up due to previous responses they had received from the management team. Staff could tell us what whistleblowing meant and had received training, and the provider had a policy and procedures in place.

People and relatives told us they could raise any concerns they had. However, the provider failed to operate a robust compliments and complaints system to demonstrate such concerns were actioned in a timely way or positive feedback was cascaded to the staff team. This was a missed opportunity to use feedback to help drive improvements within the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff felt the management team considered their equality, diversity and inclusion and treated them fairly and that their equality and diverse backgrounds and culture were taken into consideration.

Key staff members such as the nursing team and kitchen staff did not receive robust training to enable them to adequately and safely fulfil their roles. We saw that staff had received equality and diversity training. However, the system to assess staff knowledge and skills following this learning, or how they applied this in the service, was not consistently implemented. The registered manager told us that if staff required additional support with learning, they would facilitate this, such as providing additional face to face support to go through any questions they may have as a result of their training.

There were no systems in place for matching staff to people, for example, if a person spoke a particular language although there were staff available who spoke multiple languages. The processes for staff recruitment, induction, training and on-going monitoring required improvement.

Many staff told us there were happy working for the provider and many staff had been in the service for many years.

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

The provider continued to operate ineffective processes or systems for the monitoring of the quality of care provided to drive improvements. The provider failed to operate robust quality assurance systems and processes to support the registered manager in identifying the on-going concerns we found. For example, we found inaccurate and unclear information in people's care plans and risk management plans. Management of risks to people was poor. We also found poor oversight of hazards in the care environment and required improvements to keep people safe from harm. There were inconsistent records in relation to people’s food and fluid intake, repositioning and safety checks. We found a continued lack of analysis of incidents, accidents and complaints, and the subsequent cascading of lessons learnt. There was missing information in staff files.

The provider failed to carry out robust staff recruitment checks to identify discrepancies in staff records, which was unsafe. In addition, systems to assess the effectiveness of staff training were not robust in making sure staff were competent to carry out their roles. This lack of oversight meant the provider could not assure themselves their staff were skilled and had the necessary knowledge to undertake their job roles.

The provider had failed to ensure their safeguarding processes to identify when people were at risks of abuse were robust. Where safeguarding concerns had been identified, the correct actions were not always taken, and concerns were not always reported to us as per their legal requirement. During this inspection we raised several safeguarding alerts to the local safeguarding team as we found people were at risk from harm. Audits of care plans and risk assessments had not identified the discrepancies and missing information we found. This meant people were placed at risk as the provider's systems failed to provide staff members with robust information to keep people safe.

We found the provider had at times failed to follow their own policies and procedures. This meant they were not always meeting the requirements of current legislation. In addition, they had failed to carry out robust environmental risk assessments to ensure the safety of people and staff.

We found the provider was failing to fully meet the Accessible Information Standard (AIS). The AIS is a framework put in place from August 2016 making it a legal requirement to for all providers to ensure people with a disability, sensory impairment or those who required information in another format such as preferred choice of language or large print was provided to comply with AIS.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff told us how they worked with other health professionals and could make referrals to health and social care professionals via the management team. Relatives we spoke with, and the provider confirmed relevant health and social care professionals were involved with people’s care. However, we found some incidents where healthcare referrals had not been made in a timely manner, such as when people returned from hospital and further referrals to other health professionals were required but not actioned. Staff had limited knowledge and awareness of complex dementia and distressed responses. This demonstrated that more collaborative working with specific health professionals and enhanced training would improve outcomes for people. The management team acknowledged this and told us that they would arrange additional training.

We received feedback from health and social care professionals we contacted as part of the assessment process. Overall health professionals were complimentary about the service and were committed to improving outcomes for people living at the service and working with the management team to achieve this.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Shortfalls in the quality and safety of people’s care were found at this assessment. At this assessment, and over the course of our previous inspection of the service, we have identified significant concerns in relation to the safety and quality of people’s care, several of which represent repeated failings. There was a lack of robust systems and processes for assessing and monitoring the safety and quality of people’s care. This meant that lessons learnt had not been identified and cascaded throughout the service to drive improvements. Our assessment identified 4 repeat breaches of regulations relating to dignity and respect, gaining consent, safe care and good governance. We also identified 4 new breaches of regulations relating to the provision of person-centred care, complaints management, staffing and fit and proper persons employed.

The provider had failed to meet their legal requirements and demonstrate a commitment to drive the improvements in people’s care.

We also found a continued failure to improve the assessment and admission processes.

Although monthly evaluations of care plans were taking place, these were not robust in identifying where changes in support plans and risk assessments were required.

The provider supported some people with complex dementia and associated distressed behaviours. Care records and staff training to meet the needs of people needed further development, so they better reflected current best practice guidance. Further work was required to demonstrate how the provider was analysing the causes of people’s distress and anxiety, including what worked well in the reduction of such distress or what the triggers were. This meant they had missed potential indicators which could significantly improve the lives of people they supported. They had also missed opportunities to promote people’s independence to ensure they enjoyed a full and meaningful life.