Brantwood Hall 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 good. 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 legal regulation in relation to staffing and good governance.

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 understand the challenges and the needs of people and their communities.

Leaders failed to ensure all people consistently received high quality, safe care. We asked a provider level leader and the registered manager whether they knew the current values and vision at the service. A provider level leader told us, “I can’t remember them” and the registered manager told us, “I’m being honest no.” There was no evidence of a shared direction and minimal evidence of a positive and proactive culture between the leaders and staff team.

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.

There was a high turnover of managers at the service with 3 having been in post during 2025, with gaps between managers, covered by the deputy manager and/or provider level leaders. The registered manager, in post at the start of the assessment, did not demonstrate the skills and knowledge to support effective leadership. Both the registered manager and provider and had failed to maintain effective oversight of the service to support quality care delivery. A provider level leader told us they had been reviewing the registered manager’s performance prior to our assessment, but felt concerns were related to them being new “not capability.” They failed to robustly address performance concerns prior to our assessment. Following our second site visit a provider level leader informed us the registered manager was no longer working at the service.

Staff did not always feel leaders were effective and supportive. One staff member told us, “There are disputes amongst [leaders] higher up with each other. I think they try and catch each other out on what hasn't been done. The staff are not appreciated or thanked. We are talked to like rubbish. We are a scapegoat. They don't admit where they failed it's always us. It's sad because we are a great team. The gaps are higher up.”

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

Staff felt able to raise concerns. However, they did not feel that these were always listened to and acted upon. For example, concerns regarding staffing numbers. In addition, 1 staff member told us about continually reaching out to the registered manager to address a concern and not being responded to. They also felt information was not always kept confidentially.

The provider had systems in place, including a whistle blowing policy, to support speaking out.

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

The provider employed a diverse workforce from a variety of backgrounds. Systems and processes were in place to support flexible working and the introduction of reasonable adjustments when needed. However, not all staff felt heard. Feedback from some staff suggested gaps between leadership and the staff team, where they felt they were not fully supported in their role.

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.

Quality assurance systems and processes were not effectively implemented to ensure safety and quality improvement. There was a lack of robust provider level and registered manager oversight at the service. Whilst audits were completed, quality assurance systems and processes had either not identified and/or addressed concerns found during the assessment process. For example, concerns relating to fire evacuation risk; medicines management; falls oversight; service user equipment; record keeping; investigating and appropriately notifying concerns; Deprivation of Liberty safeguards (DOLs); pre-admission assessments, appraisals and staffing. We identified regulatory breaches in relation to staffing and good governance.

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.

A lack of oversight and robust monitoring of the service impacted the effectiveness of collaborative working and sharing of information. For example, appropriately sharing concerns and notifying partner agencies. Where concerns were identified during the assessment process the provider did not notify the local authority.

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.

The provider failed to effectively implement processes to assess, monitor and improve the quality and safety of the service. This resulted in significant shortfalls being identified during the assessment. Timely action was not always taken to address concerns identified through the providers quality assurance checks. In addition, timely and robust action was not always taken in response to concerns identified and shared with the provider during the assessment process. Assurances provided during the assessment were not always accurate.