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 assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in continued breach of legal regulation in relation to governance at 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 provider 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.

Everyone we spoke with told us Breach House was a nice home. A visiting friend told us, "I visit lots of care homes in my job with the church, but this is the nicest care home we’ve been in." More than one person told us they would recommend the home to others. One person said, "I would recommend this place to other people. I think it’s a good place." Another person told us, "I would recommend this care home to anyone. I’m very happy here." A relative said, "I would suggest this care home for anybody; I think it’s excellent."

Staff told us the culture of the home had changed dramatically. They explained how it previously felt task-orientated and had changed for the better. Staff were now in the right roles and did not cross over into other jobs, such as working in care and the kitchen at the same time. People’s care was person-centred and delivered in line with their needs and preferences. They also told us the team worked well together and communication had improved. One staff member said, "It’s the nicest place I have ever worked."

While the service has faced leadership challenges, not all leaders always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Some gaps in skills, knowledge, and governance oversight remain.

However, we received consistently good feedback about the provider and interim manager. Staff spoke positively about them telling us they were approachable and supportive. We also found them to be open and honest with us during our inspection. They knew there were still improvements to be made and governance and oversight required strengthening. The manager confirmed with us following the inspection they intended to register with the Care Quality Commission (CQC) as the registered manager. They told us they were committed and passionate to improving care, creating safety and high quality, and bringing stability to residents, families, and staff.

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

Staff told us they could speak up and felt any concerns would be acted upon. Staff had opportunities to raise any issues through meetings and supervisions. They told us the manager and provider were supportive, and they could approach them about anything. Staff were aware of and new how to access the whistleblowing policy.

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 were supported with training, qualification and career development. One staff member told us how they were currently completing the NVQ Level 4. There were regular team meetings, appraisals and supervisions for staff. Staff spoken with told us they were treated well, felt respected and valued and Breach House was a good place to work. There were processes in place to ensure staff were treated fairly.

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

Although improvements had been made and the provider had acted on several issues identified at the previous inspection, these improvements were not always implemented in a timely manner. Some issues were also still present at this inspection. For example, although risks regarding falls from windows and heights were mitigated, outstanding actions remained for the hot running water in some areas, 2 defective fire doors, and with Personal Emergency Evacuation Plans (PEEPs) which lacked fully accurate information. In addition, MCA assessments were not always being completed for all specific decisions people were unable to make for themselves.

There had been changes in the provider's staffing, and there was no registered manager or deputy manager in post. The manager told us they intended to register with CQC as the registered manager. They knew the service and the people they supported well, having worked at Breach House for numerous years in various roles, including as a registered manager in the past. Consequently, some improvements in the day-to-day running of the home and the provider's oversight of quality and safety were not yet fully embedded and require time to be sustained. Additionally, some audits and checks in place could be further strengthened by adding more detail.

The provider did not always understand their duty to collaborate and work in partnership to ensure services worked seamlessly for people. They did not always share information and learning with partners or collaborate effectively to drive improvements. However, we saw some areas of progress. For example, the provider worked alongside the local authority to review and resolve issues arising from quality monitoring visits, though these improvements require embedding and sustaining. While visiting health professionals reported staff collaborated well with them, these positive steps need more time to deliver lasting improvements in people’s care. Furthermore, at the time of the inspection, the provider had not established strategic links with charities, user groups, or support networks to enhance the care experience.

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

While the provider had arrangements in place to support continuous learning and improvement, these were not yet fully embedded or consistently sustained. Further development of oversight and governance processes was required to ensure positive outcomes and protect people’s safety. During this inspection, we identified recurring concerns from our previous assessment, including deficiencies in business continuity plan, Personal Emergency Evacuation Plans (PEEPs), and Mental Capacity Act (MCA) assessments. This demonstrated opportunities for learning and service improvement were sometimes missed. Further work is needed to ensure concerns are identified promptly, addressed, and any improvements made are firmly embedded and sustained over time.