Bromford Lane Care Centre

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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

The provider’s governance and quality assurance systems were not sufficiently effective to ensure the delivery of good quality care and support. Audits and checks completed had not enabled them to identify and address a number of significant concerns we found during this assessment. These included shortfalls in the assessment and management of risks to people. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff and management were not always clear about their individual roles and responsibilities, including the application of the MCA, DoLS and best interest decisions, taking a blanket approach in many areas of support. Some health professionals told us the provider did not always liaise effectively with partners for improvement. This included a lack of clear information and guidance for staff in people’s care plans and risk assessments following changes. Most staff told us they felt well-supported by management and felt confident about speaking up at work.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most staff we spoke with understood the vision for the organisation and supported the management approach to drive improvements for people using the service. Others felt this was not a shared direction or positive culture. Some staff spoke about a negative, culture in the service. Staff and management told us they understood the importance of listening to the views of people and their relatives of the service. Staff and the management team did not demonstrate a clear understanding or implement the principles in relation to people’s human rights. The provider and registered manager have been transparent and shared their findings from audits of the service which have identified shortfalls to be actioned. They have been receptive to our findings and have already started to implement changes to improve the way they support people.

Not all staff had a shared vision and values regarding the care and support delivered. Relatives had been provided with clear information on how to raise suggestions and concerns about the service. The provider sought feedback from people or their relatives, to give them an opportunity to contribute and share feedback. Reviews of people’s care plans had not always ensured a fully inclusive and collaborative process of care plan development. The provider’s processes and training provision required a more robust, consistent approach. Risk assessment and care planning processes had not always resulted in care plans which reflected and acknowledged people’s diverse needs, including the need for private time. This meant staff, who did not know the person well, may not respect their privacy resulting in an impact on their emotional responses. We saw that a monthly newsletter is produced to share information of what takes place in the service and other information of interest including how to complain.

The management team told us how they work to improve the service for people living there and their loved ones. They told us about the systems and processes they have in place to ensure people are supported in a compassionate way. However, we found these were not always effective.

We found improvement was required to ensure all staff and service users were included in the running, development and improvements in the service meetings, questionnaires and supervisions. The current systems in place do not lend themselves to help the provider or registered manager to drive improvements. The providers support and oversight of the service has not been as active as it should as per their own processes, to support the registered manager in the development of the service and the team.

Staff told us they knew about the service’s whistleblowing policy and hotline and knew how to raise concerns if they had any. Some staff told us they had felt they were unable to speak up due to the potential responses they would receive from the management team. This was also reflected in the staff questionnaires. Although some comments were of a negative nature, overall comments about the management were positive. Other staff members told us how the registered manager operated an open door policy and they felt able to raise concerns as they arose. We saw this was the case during the assessment. Formal feedback from staff had recently been gathered but had not been analysed. However, this was completed during the assessment period.

There was a whistle blowing and safeguarding policy in place although this had not always been followed by staff. Staff were informed about this as part of their induction. Service user meetings had not been held between June 2023 and June 2024. One relative told us how they used to find these a positive way of keeping up to date and meeting the manager and other relatives. Systems to encourage people using the service to be able to communicate and speak up required further improvement. The feedback forms used for staff are more about whether the manager has carried out their responsibilities rather than being used to help gain feedback to help drive improvements in the service and for people who use the services.

Most staff felt the management team considered their equality, diversity and inclusion and treated them fairly. Most staff we spoke with felt included in the making of decisions and helping to drive improvement within the service. Most staff felt that their equality and diverse backgrounds and culture were taken into consideration. However, some spoke of a negative culture in the service.

Team meetings and supervisions did take place but had not been used as effectively as they could. The provider told us how they have support systems which they can link into to help staff who need additional support to develop both language and professional skills. At the time of the assessment no staff were engaged in these, but it was evident that some staff would have benefitted from this additional support. Some staff had received equality and diversity training but there were a fifth of staff who had not. This was not in line with the providers own policy.

Staff and management we spoke with told us they were clear about their individual roles and responsibilities as these related to delivering good-quality care. However, we found practices and the information they gave us did not always reflect this. For example, fire evacuation, updating care records in a timely way and safe medicines administration. The provider was unable to provide us with assurances in relation to their oversight and governance of the service in particular the application of ‘blanket’ approaches and DoLS. The management team were aware of when to notify incidents to the relevant external agencies. The registered manager told us they understood their role and responsibilities. They also told us overall they now felt supported by the provider, but this had been lacking in recent months. The provider told us there had been a change in relation to the quality team, but a new quality lead had been allocated to the service. Feedback from health professionals and relatives was overall positive and were happy with the management of the service.

The provider’s governance systems were not effective enough and had not enabled them to monitor and manage risks to the safety and quality of people’s care. The provider has been transparent and shared their findings from recent audits of the service which have identified shortfalls. Provider oversight was lacking and quality documents to assess the service were not robust. The most recent audit completed in April 2024 scoring does not reflect what the comments and findings indicate. The scoring indicates the action has been met when in fact the comments indicate they have not. The time taken to carry out such actions, at times had not been met for several months, which has the potential to impact on people who use the service. The governance systems failed to ensure systems and processes were operated effectively. This included the oversight of staff files, training needs of staff and competency assessments which would help to evidence what staff had learnt from training received such as MCA, fire and medicines, poor mitigation of known risks including storage of cleaning products and flammable products had not been identified. There was a failure to involve people in care planning and assessments when initially moving into the service and this was carried out by a staff member working from home. There was a failure to act promptly in response to people’s changing pressure care needs. The provider and registered manager had failed to review and implement risk assessments such as ligature, food safety, bird aviaries and the potential risks of disease and pest infestations. The provider had failed to ensure their own policies and practices were consistently being implemented and adhered to. The daily staff handovers, meetings with professionals to discuss progress and plan discharge on the EAB unit, managers walkabout and monthly clinical meetings were all positive aspects of the service. Clinical meetings and risk boards were good sources of information sharing.

People told us they had access to the community and were supported to participate in their preferred activities and visited places of interest to them. This included meals out and trips to the pub. We saw evidence that when people required additional support this was organised in a timely way. People and relatives told us, and we saw that local schools and entertainers came into the home.

Staff and leaders told us how they worked with other health professionals to ensure the best outcomes for people using the service. We observed a meeting with professionals taking place and how this impacted positively on people using the service. The manager and deputy manager of the EAB unit told us how these meetings have really helped improved the time people spend on the EAB unit before moving to their permanent place of support.

Other health professionals gave positive feedback on the service and the positive outcomes the service achieved for people using the service. Health professionals based at the service told us how the information provided prior to moving in was poor but the process to discharge people to new services worked well.

The processes used by the provider required improvement to ensure they involved people using the service. This included gaining consent and involving people in their care planning when first moving into the service. Whilst the moving in process could be improved with better information sharing by the hospital discharge team the process when leaving the service was much smoother.

The registered manager and provider told us how they took lessons learnt from incidents and shortfalls within the service. However, we found that areas of improvement identified in the Quarterly Quality audit carried out by the provider in July 2023 were still occurring.

Processes required improvement ensuring learning was taken from shortfalls in the service. This meant we could not be assured that the systems and processes in place were robust. The provider had failed to have oversight of the service as per their own policy of quarterly audits. This contributed to the identification of areas of required improvements and practices being in place which are not reflective of the regulations. This meant that lessons learnt, and improvements had not been cascaded throughout the service.