Brailsford House

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

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.

The provider was previously in breach of legal regulation relating to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

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 focused on providing people with person-centred care, in a secure, relaxed and homely environment, where their care, wellbeing and comfort were a priority. Management and staff provided people with care which reflected that aim and was individualised, safe and reflected what was important to people and their families. One person told us, “There’s no better place. It’s a homely place. I can talk to them.” A staff member commented, “The main focus is the residents and how they want to be supported.”

The registered manager ensured staff were clear about their responsibilities and the aims of the service, which were discussed during regular meetings. Audits were used to identify where staff practice required improvement and lessons learned from accidents, incidents and complaints were shared with staff during meetings and in memos, to support learning and development.

The registered manager possessed the knowledge, skills and experience necessary to manage the service well and ensure staff provided people with good quality, person-centred care. They had been in post since 2021, so knew people living at the service and staff well. A deputy manager was in post who supported with the day to day running of the service.

The registered manager stayed up to date with good practice by completing regular training and reviewing regular updates received from CQC, Skills for Care, National Institute for Health and Care Excellence (NICE) and the Department of Health and Social Care. They ensured relevant information was communicated to staff, who were supported to learn and develop through team meetings, supervisions, handovers, training, competence assessments and management discussions.

People and relatives were happy with how the service was being managed. One person told us, “I think they do a very good job. I am comfortable and I want to stay here.”

The registered manager and deputy manager created a culture where people could speak up, and they would be listened to. People and relatives were encouraged to raise any concerns about the service and told us they found the registered manager approachable. One person told us, [Registered manager] is lovely. I can speak to her if I need to. She listens to me and I can talk to her.”

The staff handbook provided information about how staff should raise concerns or make a complaint. Staff told us felt able to raise concerns with the registered manager or deputy manager. They felt confident they would be listened to and any concerns would be acted upon.

Staff were aware of community agencies they could contact with any concerns, including the local authority and CQC.

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 told us they were happy working at the service. They felt respected, valued and told us they were treated fairly. They could raise any concerns with the registered manager, deputy manager or senior staff.

Staff were able to raise concerns and make suggestions at regular meetings, supervisions and through surveys. A summary of the staff survey from May 26, showed staff were generally satisfied with support, training and development and the quality of care provided at the service. Some felt improvements were needed with communication and the home environment and these issues were being addressed.

The provider and registered manager ensured regular audits of quality and safety were completed, and most showed action was taken, or action plans were put in place, when improvements were needed. We noted the issues we found around staff training not having been completed or being overdue, had not been addressed as part of the quality checks completed, and there was no plan in place to follow this up. We discussed this with the registered manager and provider, who advised they would review their processes to ensure any similar issues were addressed in a more timely way in the future.

The provider had a Business Continuity Plan, which included the action to be taken in the event of incidents such as severe weather, flood, fire and outbreak of infection. This meant there was a safe system in place to ensure that, during periods of potential disruption, people would remain safe and supported.

Management and staff worked well with partner agencies, such as GPs and community nurses, to ensure people received the care and treatment they needed to meet their needs and experience a good quality of life. Staff attended a weekly GP review where concerns about people’s health and wellbeing could be discussed and any investigations or treatment arranged. In addition, referrals were made to a variety of community services, including community nurses, physiotherapy and speech and language therapy, for specialist support when needed.

Where community professionals were involved in people’s care, staff communicated with them regularly, providing updates and identifying concerns or improvements. This helped to ensure people’s health and wellbeing was monitored; action was taken when there were any changes and they were provided with a seamless service. We received positive feedback from 3 community professionals who visited the service regularly. They felt staff provided people with high-quality care and told us the service worked well with them to ensure people received appropriate care and their needs were met.

The provider and registered manager focused on continuous learning and improvement, to deliver positive outcomes and a good quality of life for people. Staff provided people with person-centred care and worked well with partner agencies to meet people’s needs and manage their risks. Staff followed advice and guidance provided by partner agencies, to ensure the care they provided was safe, effective and met people’s needs.

The registered manager welcomed opportunities to improve and develop the service. They used audits, incidents, complaints, safeguarding concerns, feedback and lessons learned as opportunities to identify areas for improvement. Any changes to practices and processes were shared with staff to ensure the support they provided reflected good practice. The registered manager encouraged an open culture where staff felt able to raise concerns, discuss practice and contribute ideas for improving the quality and safety of the service. They recognised the importance of maintaining their knowledge and leadership skills and their ongoing professional development.