BH Residential Care Home

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. This is the first assessment for this service. This key question has been rated 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 provider was in breach of legal regulation in relation to governance of the service. The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Staff felt comfortable raising concerns, although information about speaking up needed to be more accessible. The home had undergone numerous managerial changes since registering with CQC, which had affected the running and oversight of the home. The current manager was experienced, and staff were complimentary about how they were settling into the home. The manager understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

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.

The provider had an up to date statement of purpose in place, which contained some references to the organisations culture and values. As previously mentioned, the lack of managerial consistency had not helped with the creation and maintenance of a consistent approach and shared culture. We also identified communication around changes needed to occur more timely. The family members and most of the people we spoke with during the assessment were unaware the previous manager had left and the current manager had taken over.

At the time of assessment, a new manager had recently commenced in post. They had been in the role full time for less than a week, but for the previous month, had spent 1 – 2 days per week working in the home, whilst serving notice in their previous role. The new manager was known to CQC through their experience in working and managing care homes across the North West. Although still early days, staff spoke positively about the manager, who they said was approachable and happy to help out where needed. The manager had used their experience to identify a number of improvements which were needed. They told us initially they wanted to set up a detailed filing system, to ensure they had better oversight of everything within the home.

Staff told us they were happy to raise concerns and had an understanding of whistleblowing and what this meant. The provider had up to date policies in place relating to speaking up and whistleblowing. Staff were provided with a handbook when they commenced employment. We reviewed this as part of the assessment and noted it predominantly provided information on what to do in an emergency. There was no information about speaking up or whistleblowing, or other aspects of staff’s role and rights. We fed this back to the manager and suggested they review the handbook to ensure it met staff’s needs.

Staff told us they enjoyed working at the home and felt supported. Staff meetings were held, which allowed staff to raise any issues or concerns and receive information about the home and ways of working. The last meeting had taken place in September 2024, when the previous manager was in post. Staff were unsure how often meetings should be held and we saw no annual schedule in place or on display during the assessment, which would be best practice.

The home had undergone numerous managerial changes since registering with CQC, which had clearly impacted on consistency. At the time of assessment, the current manager was the fourth within 20 months. It was apparent the provider did not have clear structures, systems and processes, which each manager needed to work under, with each new manager introducing their own ideas and systems. As a result, audit and governance processes were still a work in progress and it was not clear what checks and monitoring should be completed and how often. The provider was using a mixture of internally created audits, along with ones provided by an external compliance company. As the external ones were generic, work was needed to adapt these to ensure they were suitable for the home. Audits which had been done had not identified issues or shortfalls, including the issues we noted on assessment. Governance meetings had commenced in December 2024, which were attended by the manager and the provider. These would be an ideal forum for reviewing the audit and governance process, ensuring this had been completed in line with schedule and discuss any actions and lessons learned. However, the 2 meetings held per date had mainly consisted of a discussion on how the manager was settling in and making plans for the Christmas period.

The provider worked in partnership with other professionals and stakeholders to ensure people received the care and support required. During the 3 site visits we completed, we observed a wide range of professionals visit the home to meet with people, provide care or therapy. The provider had made links with a local nursery, who had asked if their children could visit the home. This was facilitated in November 2024. Following the visit the nursery had emailed the provider, thanking them for allowing the children to visit. They stated the visit was a meaningful and enriching experience for the children and thy hoped to continue building on this connection. The current manager told us this was something thy would actively pursue. The manager had also made links with a local theatre group who were due to attend the home to sing and do some drama. Although it had been arranged as a one off visit linked to Christmas, the manager told us they hoped to make it a regular thing.

The provider had an overarching action and improvement plan in place. However, this centred around issues which had been identified by external stakeholders, specifically the local authority and their quality monitoring team, rather than through the providers own governance processes. We also found clear timescales had not been attached to planned improvements, as some actions from meetings with the local authority in July and August 2024 were still to be done. There was a lack of systems and processes in place to identify patterns and trends and consider lessons learned. This applied to accidents, incidents and safeguarding. There was also no clear system in place for feeding back actions planned or taken in response to people, relative or professional feedback, which had been gathered through feedback forms or meetings.