Bryn Haven

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• 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

Staff had access to whistleblowing procedures to raise any concerns. We received mixed feedback from staff around the availability and access to the registered manager as they were often very busy. The registered manager completed a suite of audits and oversight tools to monitor the quality and safety of the service. Periodic checks, including daily walkarounds of the service and audits of care documentation were completed by the registered manager. However, these checks had not always identified or actioned the concerns we found on this assessment, for example, thickener recordings, diet and fluid records, people’s cleanliness and concerns raised around staffing levels. The registered manager was quick to act in response to any concerns raised during this assessment. Notifications were submitted as required and people’s data was kept secure.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff had access to whistleblowing procedures and most staff told us they would speak up when needed and felt they would be listened to. Regular staff meetings were held and the registered manager told us staff had regular supervisions with them. We received mixed feedback from staff about how approachable the management team was and whether they felt confident action would be taken if concerns were raised. One staff member told us, “A lot of stuff is brushed under the carpet.” Another staff member told us they felt supported sometimes, but it was so hard at the moment with the staffing levels. However, they also told us, “If I have reported anything it has been sorted.” Feedback was also mixed around how often staff supervisions took place. Staff told us it was difficult to speak to the registered manager as she is always so busy herself. One staff member told us, “At the moment we’re always short staffed so [registered manager] is always busy and doing tasks…they are approachable but always too busy. Everyone is so stressed out at the moment due to staffing situation.”

Several processes were in place to enable staff to speak up about any concerns they may have. A whistleblowing policy and procedure was in place alongside an online ‘speak up’ facility for staff to leave anonymous feedback. The registered manager told us the Chief Executive Officer visits the home regularly for staff to come and speak to them directly. The registered manager told us they have an open door policy for staff, people, and visitors to come and talk to them about any concerns they might have. They also told us they conduct regular, unannounced night visits to ensure night staff are able to see and talk to the registered manager.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager was responsive and had implemented an action plan to address the issues we highlighted to them on day 1 of the site visit. They subsequently fed back to us what improvements had been made since we raised our concerns. However, our concerns remained as staffing levels were still below those prescribed by their own dependency tool and this had not been addressed. Staff were very direct with us that there was not enough staff at the home to enable them to provide good care. Staff told us they would not have a family member living at Bryn Haven. The registered manager told us they felt supported in their role, they had good support from their area manager and other managers. There was also a registered manager buddy system in place; they told us, “There is always someone at the other end of the phone.”

The registered manager had a support network in place and the service benefitted from a corporate suite of audits and oversight tools. The registered manager carried out many periodic, quality assurance checks, including daily walkarounds of the service and audits of care documentation. However, these checks had not always identified and/or actioned the concerns we found on this assessment, for example, thickener recording and administration, diet and fluid records, people’s cleanliness and dignity. In particular, concerns raised around staffing levels had been refuted and no action had been taken. Notifications were submitted as required and people’s data was kept secure. The registered manager understood their obligations around duty of candour and emergency policies and procedures were in place.

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

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.