Bethrey 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

The service was not well-led. We identified 1 breach of the legal regulations. The systems in place to monitor and improve the home were not effective. There were no systems in place to ensure people received the care they needed. The home was not well managed, and this was reflected in the home’s culture.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were not able to show they were aware of the values of the organisation. The Nominated individual said this was something they were looking at implementing however currently there were no agreed values in place.

The culture in the home was poor. The lack of oversight had resulted in people receiving poor standards of care by staff who were not adequately trained or competent. There was no effective induction in place which meant new staff were supported by staff who were unaware of the home’s values and who were not always adequately trained to perform their role.

During our conversations with the nominated individual, they were unable to consistently demonstrate they had the experience and capability required to effectively lead the staff to provide safe care and support. For example, they were unable to assure us they understood the process of raising a safeguarding concern. We received mixed views from staff and some raised concerns about how the home was being run.

The home was disorganised and there was a lack of leadership. Senior staff observed poor practice and took no action as they did not have the skills or knowledge to identify this. The nominated individual was unable to demonstrate they understood their role and we raised concerns around the lack of accountability. The registered manager was absent from the service. There was a lack of evidence of clear and effective leadership roles, we had a lack of assurance from the nominated individual and met with them after the site visit to share our concerns around this.

The nominated individual was aware of the whistle blowing process however was unable to confirm if there was an up-to-date policy in place. We received mixed feedback from staff, some staff felt they were unable to speak up about concerns they faced. Other staff felt confident to do so.

There were not always procedures in place to ensure staff and people felt confident to speak up, this was not addressed or monitored by the home. The policy we reviewed was outdated.

The nominated individual told us staff were treated equally and in an inclusive way. They were unaware if there was an up-to-date policy in place for this. We received mixed views from staff about how they were treated by the new providers. One staff member said, “I feel I am treated fairly here.” Whereas others raised concerns.

There were not always procedures in place to consider staffs individual and diverse needs. The policy we reviewed was outdated.

The nominated individual told us they had started to identify concerns with the provision of care. However, they confirmed there were no action plans in place for this. They alerted us to some concerns with the environment, however other concerns we identified during the inspection were not referenced by them.

Audits and checks in place were not effective. The only audit shared with us was a medicines audit and this had not identified any of the concerns we found in ‘medicines optimisation’. There were no other audits in place to monitor the care people received, resulting in people being exposed to risk.

People and relatives raised no direct concerns with this, however when asked people were not aware how or if they were involved with this.

Both leaders and staff felt they worked in partnership with other agencies. However, they also confirmed they did not refer people to health professionals for advice when needed or follow advice that professionals gave.

As part of this assessment, we asked for feedback from the local authority They told us they had recently attended Bethrey House and found concerns. They had worked with the provider to put in place an action plan which they shared with us. The local authority told us they were working with the home to action their plans however had received very few responses from them.

There were no effective systems in place to ensure they worked in partnership with other agencies. There was no oversight of peoples needs or changing needs. When changes occurred, staff did not always record this or share with the management team so that action could be taken. The management team did not review care notes or plans and therefore were unaware what action was needed.

The nominated individual told us they had recognised areas of the home that needed improving. When asked they confirmed there was no action plan in place for this. They were able to verbally tell us about concerns with the environment for example however when asked they failed to identify and discuss the concerns we identified around people’s care. Staff were not aware of or able to share with us how they were involved with any learning. They were also unable to share how they were involved with the running of the home and felt they were not always part of this.

The were no effective systems in place that enabled safety and quality concerns to be identified and acted on. This meant learning, improvement and innovation were not always promoted. For example, effective systems were not in place to learn from safety incidents.