Breach 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

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 inspection 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 a legal regulations in relation to governance of the service.

This service scored 29 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We observed staff were task focussed which was not identified or challenged by the manager. The culture of the home was not always person-centred. We have reflected throughout this report, that people’s care needs were not always being met adequately or in line with their preferences. There was a lack of oversight to ensure people were supported appropriately and engaged in a way that was meaningful to them.

The provider did not deliver a safe environment or promote a culture of safety to ensure the approach of staff was in line with the principles of dignity and respect. Therefore, the staff team were not able to learn from incidents, which meant people did not receive good care. Most staff felt there was limited guidance from the manager and provider.

The leadership team did not demonstrate the required skills or capability to deliver person centred care or to ensure risks were well managed. There was culture of providing care to people rather than involving them or encouraging them to remain independent and make decisions about their own care.

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.

In addition, we found there was a lack of transparency from leaders. For example, we found rotas did not reflect which staff had worked each day and meant it was difficult to identify the number of staff supporting people each day to ensure people were safe. Additionally, documents had been amended between our visits, without clear explanation and did not record who had made the changes. This meant the provider could not be assured if documentation was accurate.

The manager had failed to act on the issues impacting people, staff and the service in a timely manner, and had not identified the shortfalls found during inspection. Staff told us although the manager was approachable, but they were not visible within the service and spent a large amount of their time in their office or working from home. Most staff did not feel confident concerns raised to the manager would be dealt with. Following our inspection, we received feedback from anonymous members of staff who alleged there were multiple medicines errors at the service which are covered up by the manager. Staff told us they raised these concerns with the provider’s representative but reported feeling it was “brushed under the carpet and covered up”.

Quality assurance processes were limited and not robustly implemented. The provider had not had oversight of the service to ensure the management team were providing safe, high-quality care, as they did not undertake audits to identify potential shortfalls.

People did not always feel they could speak up, and their voice would be heard. Some staff members expressed a lack of confidence in the manager’s ability to act on concerns raised. Although staff felt able to speak up to leaders, they did not always feel any action was taken.

However, prior to, and following the inspection, we received feedback from anonymous staff members that they had concerns about the service but had not felt empowered enough to speak up for fear of retribution. Feedback suggested a blame culture had developed within the service and staff felt they were being blamed for mistakes the manager and provider had made. This indicated that systems currently in place were not effective for some staff.

The provider had an equality and diversity policy in place. Staff had undertaken equality and diversity training. Feedback from some staff indicated they didn’t feel they were treated fairly, and the manager didn’t work towards an inclusive approach.

We also identified concerns that not all staff had opportunities to have one-to-one discussions or supervision with their manager. The manager told us they would keep contact with staff via a WhatsApp chat. However, staff we spoke with told us they would only hear from the manager, if there was a specific need.

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 manager and provider’s representative had not been effective in identifying the areas of improvement in the home environment to reduce the risk of people injuring themselves.

The manager did not have an overview or insight of the service. Audits in place did not identify concerns we found during our inspection in relation to safe care and treatment, training, safeguarding, person centred care, IPC and good governance.

The manager and provider did not check the quality of audits, or daily note records to ensure people received the most appropriate care to meet their needs. There were no action plans in place to ensure actions from audits could be monitored and implemented.

The systems in place to record and monitor accidents and incidents at the service were not being used effectively to ensure actions were taken in a timely way. Risk management was poor and there was a lack of analysis to establish the cause and if any lessons could be learnt and shared with staff to prevent a recurrence and any potential harm to the person.

On discussions with the management team, they lacked any understanding of the principles of national guidance and legislation including MCA.

Leaders were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service, and people continued to experience poor outcomes because of these failures. There were no audits undertaken during the night shifts to establish if there were any concerns or any areas that required improved. There was a lack of oversight, accountability and governance. This put people at increased risk of harm due to the failures in effective oversight.

Whilst staff undertook various audits, governance systems were ineffective because they had either not highlighted or fully addressed the concerns we identified during the inspection. We identified issues in relation to the deployment of staff; training and supervision; safe management of risk, safeguarding people, suitability of the premises; providing person- centred care and the need for consent. The manager was not aware of all aspects of risk within the service.

Care plan audits were reportedly undertaken but we could not find any documented evidence these had taken place. We found these audits had not effectively identified and addressed all the issues we found. Care plans were not fully reflective and up to date in relation to people’s support needs.

Additionally, the provider had consistently been rated requires improvement since 2019. The leadership team failed to make the improvements needed and to ensure the changes were embedded to improve the lives of people living at the service and staff.

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.

Care plans and risk assessments did not reflect people’s current needs. Therefore, it was unclear how accurate information was being shared with other health professionals involved in people’s care. People and their relatives told us they were confident the service would contact healthcare professionals when required.

The manager and provider did not work collaboratively with partners and stakeholders. External professionals told us there was a lack of action taken by the provider to engage and be accountable for the failings the local authority had identified since April 2025.

The failure to collaborate, lack of transparency, and unsafe misinterpretation of professional guidance not only meant that people were failed by leaders they put their trust in to keep them safe, but they were at ongoing risk of harm.

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. There was no evidence that lessons had been learned from accidents, incidents, or falls, due to the absence of meaningful action to review and analyse these events for trends, patterns, or opportunities for improvement.

Quality assurance systems were ineffective, which limited the provider's ability to drive improvements that promoted equity and positive outcomes for people. Concerns relating to lack of window restrictors and wardrobes not being secured to walls had been highlighted during a previous inspection we had undertaken. The provider had not reflected and learnt from this, and we found the same issues again.

The lack of effective systems and management meant there was no drive to improve the safety of efficacy of the care and support being delivered. Risks were not identified or actioned to ensure people were safe, there was no focus on improving the safety for people and reducing the risk of injury.

The manager did not have oversight into how care was delivered. This meant opportunities to analyse and review accidents and incidents for themes and trends did not occur. Learning was therefore not identified and consequently not shared with staff. This meant improvements to the service and the care people received were not considered or implemented.