Branch Court 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 inspection we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Although there were some examples of good management structures in place there were some shortfalls in service leadership and appropriate oversight.

The service was in breach of legal regulation in relation to the governance of 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 service 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 spoke about the visions and values of the service. One staff member said, "I think it is about supporting people to live their best life." Various policies were in place to support an open culture, and the registered manager told us, "I have an open-door policy.” This was echoed by various people we spoke with throughout our assessment.

The service 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, though issues we identified had not always been actioned, despite the registered manager being aware of these prior to our assessment. The registered manager acted with integrity, openness and honesty.

We found the management team approachable, compassionate and open throughout our assessment, though whilst the registered manager was aware of some of the issues, we identified during the assessment these had not always been actioned for example the concerns identified in relation to staff supervisions. Staff told us they felt supported in their role and that the management were approachable and fair to staff.

The service fostered a positive culture where people and staff felt they could speak up and their voice would be heard.

Staff knew how to whistleblow and they felt confident to speak up should they need to. The provider had a whistleblowing policy available to staff. Staff were able to raise any concerns in team meetings. Staff surveys were conducted in August 2024 to gain staff feedback, all completed surveys contained positive feedback.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they were treated equally and fairly in a compassionate way. The service employed a diverse range of staff. Staff comments included, "I think it (staff morale) is ok." An equality and diversity policy was in place which set out how they supported equality and diversity, but this focused mainly on staff.

The service did not always act in line with their responsibilities, roles, systems of accountability and governance procedures. They did not act on the best information about risk, performance and outcomes, and information was not always securely stored.

The service was not acting in line with some of their policies. For example, the training policy provided information and guidance about mandatory training being completed, but this was not always the case. The supervision policy indicate how often staff should receive supervision, but this was not being followed, and the end-of-life policy detailed the expectation for staff to complete training in end of life, but this had not been delivered. Although audits and oversight tools were in place they did not always identify the issues we found during our assessment, and where they did identify issues or action required, the registered manager did not always act on these. Various records were not up to date. For example, a training matrix included staff no longer working at the home and a statement of purpose was displayed that was not the most recent version.

People’s personal records were not always being securely stored. There was a cupboard on the landing that contained people’s personal records which was not locked. During the assessment a lock was added to the unit. People’s records did not always appear to be appropriately completed or as detailed as they should have been. For example, fluid intake charts did not always show that people were receiving enough fluid. We saw no evidence that this had any impact on people, and we witnessed fluid and drinks were readily available throughout our assessment, so this was likely to be a recording issue.

People who were supported by Nobi Lights (which is a technology used to assist staff to support people who are high risk of falls) did not always have this information recorded in their care plans. People’s records did not always contain accurate information. For one person who was living with epilepsy, their care plan stated staff had undertaken basic epilepsy training to ensure they were equipped to respond appropriately should a seizure occur. However, on review of the training matrix, we found this was not the case. The service does not have appropriate registration in place to support one person in the service.

At our last inspection we noted the provider had failed to operate effective systems to assess, monitor and improve the quality and safety of the service. The provider had also failed to maintain accurate, complete and contemporaneous records in respect of each person. These issues have still not been fully addressed as per our findings in this report.

Staff told us they felt the management carried out regular checks on safety and standards of care.

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

People’s relatives generally felt they were kept up to date and relevant healthcare professionals were involved when needed. The registered manager told us how they worked in partnership with and involved external professionals such as the local authority, advocates, district nurses, social workers, stroke team, dentist and GP when needed. We have been able to gather limited feedback from partners despite our requests. However, one professional told us about their positive relationship with the service and told us they felt respected and valued as a health professional. People could gain access to advocates when needed, and it was evident that people used advocate services to support them when needed.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Although they encouraged creative ways of delivering equality of experience, outcome and quality of life for people, they did not always actively contribute to safe practice and research. This is highlighted through our continued concerns identified during this assessment.

The provider had failed to act on some of the concerns identified at our last inspection which has led to a continued breach at this assessment in relation to governance and oversight. The registered manager spoke about lessons learned, they told us, "I record on accident and incident forms the lessons learned and what to do to mitigate reoccurrence." We saw some examples of lessons learned following incidents, and we saw how the registered manager analysed areas such as falls to look for patterns and trends and made referrals to ensure appropriate support was being offered to people. We saw some examples of innovation in ways such as using technology (Nobi lights) to support people who were at a high risk of falls. These lights alerted staff to any falls in people’s bedrooms which ensured that people were responded to quicker following a fall, which can improve the outcome for that person.