Bethany 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

The registered manager had the skills and experience needed to manage the service. They had a clear drive to lead the service forward and make improvements for the benefit of people and staff. There was a system of quality checks in place to identify where improvements were needed and address any concerns. There were regular meetings for staff and staff had the opportunity to raise issues and feed in to how the service was delivered. Staff were well supported and were motivated to provide good care and support. Staff had undertaken equality and diversity training and told us diversity was valued at the service. The service worked in partnership with health and social care professionals to support people in a joined-up way and provide good outcomes for people.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The providers vision for the service was clearly set out and communicated to staff. This was based on kindness, inclusivity, and learning. The registered manager told us this was inline with their own personal values, and they were committed to driving these forwards. There were regular meetings with staff which focused on embedding the providers values. The registered manager told us they spent formal and informal time with staff to build relationships and support staff to improve practice as standards had fallen prior to the registered manager joining the service. Staff were motivated in their role and positive about the registered manager. Staff told us, “The registered manager is very focussed and wants to get us back on track and see the service as a successful home for people to live in, where people are happy to live here, and staff are happy to come to work.” Another staff said, “He has come with a lot of ideas and motivation. He is determined to drive improvement. I believe in his intentions and plans. I’m happy to work with him.”

Staff met on a daily basis to share learning and discuss any changes to people’s support. There were also ‘no blame’ reviews when there were inccidents to promote transparency and encourage staff to learn from any mistakes and share their experiences. This aims to reduce the risk of similar incidents occurring. Clinical staff met and there was a system of clinical oversight in place to ensure staff had the right support and guidance in their clinical practice. It is clear there have been improvements since the new manager commenced in post.

We observed interactions between staff and the registered manager. Staff were comfortable to ask questions and seek support which the registered manager responded to in a positive way. Staff told us they could contact the registered manager at any time for support. Staff said he shared his ideas and plans with them. Staff told us even if they did not agree on an idea, “they respected each other and worked well together.” Staff told us there had been improvement at the service. One staff said, “Another positive change is that communication flow has improved; there is more clarity about the day to day running of the service - morning hand over meetings are more effective than they used to be as the day is more structured.”

The registered manager had a professional background as a registered mental health nurse. They were currently undertaking a recognised qualification in Health and Social Care Management to develop their skills and knowledge. They demonstrated they had the experience and knowledge in supporting people with their needs. They also had sufficient management experience to manage the service. The registered manager told us they were supported by the operation director to deliver their role effectively.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager recognised that a staff survey undertaken in February 2024 did not reflect positively in some areas including equality and diversity. We discussed this with them. They told us staff were unsettled as they were bringing in a number of changes and challenges as staff practice needed to be improved. There had been some cultural concerns which had developed since the last inspection. Coming in as a new manager there had been improvement needed and there was some staff unhappiness. However, this had improved, and staff were happier in their role and worked well together. One staff said, “Things are changing a lot in the service. We work better as a team. The registered manager introduced a system where we work across both services. I understand the point.”

Staff had completed training on equality and diversity. They had also completed best practice training in supporting people with a learning disability and were being supported to access level two of this training. They told us they respected each other irrespective of where they are from and what they belief.

The registered manager was supported by a deputy manager, clinical lead, who were based on site. The registered nurses supported the care staff to provide care and support to people. Both the management team and the care team had daily meeting to discuss people’s needs and the effective running of the service. Staff told us they were encouraged to share information openly and were encouraged to raise concerns. The registered manager told us it was important there was accountability when things went wrong so staff learnt lessons and made improvement.

Systems were in place to check the quality of the service, for example there were regular audits. The registered manager also undertook spot checks including checks out of office hours to review staff practice. They reviewed a wide range of areas including medicine management, safe care and infection prevention control. Where improvements were identified, and action plan was put in place and improvements were monitored. For example, a new induction process had been introduced to improve staff experience when they joined the service.

People told us staff supported them to see health care professionals where this supported was needed. They told us care staff let them know what was happening if they were waiting for an appointment.

Staff were developing close relationships with some health and care professionals. For example, the clinical lead for the service was working with the local GP to explore how they could work together better and therefore improve outcomes for people. Staff were aware of the guidance shared by health and social care specialists for people’s support.

Concerns had been raised by some health and social care professionals about the service and the support people were receiving. However, the service had been working to make improvements and most of the issues identified had been addressed or were being so at the time of the assessment. Other health and social care professionals had since been positive about the service and the support people received, they praised one member of staff specifically and also said, “The other staff also appeared polite, and we cannot fault any part of the care observed.”

Staff worked with partners to support people’s health and well-being. For example, staff worked with the speech and language team and the Home Enteral Nutrition (HEN) team where people used a feeding tube for support with nutrition and hydration. Monthly meetings were held to improve joint working in some areas.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.