Bryony Lodge

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 requires improvement. This meant the service 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 breach of legal regulation in relation to good governance.

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.

Some improvements had been made following our previous inspection. 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. We reviewed the provider’s statement of purpose which clearly set out their values which were respect, excellence, integrity, and accountability. Staff had regular team meetings and regular supervision with the operations manager. The operations manager told us the culture in the service has improved as they had taken actions to address this.The manager told us, “I speak to staff to ensure they are happy and are following the organisations policies and procedures to ensure bad practice does not take place.”

Not all leaders understood the context in which the service delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. There were concerns around continuity of leadership as the previous manager, left in October 2024 and the service was without a manager until March 2025. The operations manager had been providing some oversight, however, they also had other services to oversee so were not able to provide a daily presence. The new manager in post, told us they plan to lead with integrity, openness, and honesty. They were aware of issues and priorities within the service and were working towards improvements and changes to systems and processes. This included ensuring people lived a fulfilled life. The provider told us the new manager would start the process to become a registered manager. Some relatives told us they did not know the new manager and would benefit from some improved communication. A staff member told us, “The new manager is visible they are hands on and approachable and wants to work as part of the team.”

The service promoted a positive culture where people felt they could speak up and their voice would be heard. Staff had access to regular supervision and team meetings where they could share their views. Staff were provided with a whistleblowing policy to provide them with information on how to speak up. Staff, however, told us they felt able to speak up. One staff member gave an example of when they had done this and the positive response they received.

The service 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 felt supported to give feedback and were treated equally, free from bullying or harassment. The manager gave us a couple of examples of how they had supported staff to be able to practice adhere to their religious beliefs whilst at work.

Systems and processes to monitor the quality and safety of the service were still not always effective. Following our previous inspection the service had been without a manager for a period of time, and this meant actions required to improve the service had not always taken place. Audits had been completed in relation to fire safety, infection control, medicine management and the environment. However, these had not always been effective in identifying the shortfalls we found such as the concerns we found with the fire doors, in the kitchen and with medicines management. Where the provider had identified shortfalls such as the fire doors, remedial action had not been taken promptly to reduce the risk to people. The provider told us now the new manager was in post, and they were also recruiting a team leader, they were confident the governance would improve. They also told us, they would ensure they supported the new managers to have the training and knowledge to undertake all other audits. The manager was able to confidently tell us how they ensured safe record keeping by following the principles of General Data Protection Regulation (GDPR).

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Relatives, staff, and the manager shared positive examples with us of collaborative working in partnership. Professional’s told us they worked in partnership mainly with the operations director as there was a period where there was not manager in post. They gave us positive feedback about their interactions with them. The manager told us they hoped to build relationships with these professionals moving forward.

The service strived to focus on continuous learning and improvement across the organisation and local system. However. the service had not always made improvements following our previous inspection and we found some ongoing concerns at this inspection. Staff and leaders were working to establish a consistent approach to improvement including monitoring progress and outcomes. The provider was responsive to our findings and acted immediately on key areas of improvement. The manager told us, “Following the CQC visit we have made improvements. There is a clearer oversight. My focus is getting to know the people and the home as I have only been here for a couple of weeks.”