Brailsford 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

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.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained 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 service was in breach of legal regulation. This is because there was poor governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff told us there was a poor culture at the service. They described that low staffing levels and poor refurbishment of the building impacted their wellbeing and care that was provided. They felt that their concerns would not be acted on. They also explained they were not always consulted on how to improve the care home. Although we received mixed feedback about the culture of the service from staff; people that used the service were mostly happy with the care provided and felt the care staff worked hard to meet their needs. The manager told us 'I recognise the benefits of an inclusive and diverse workplace and team'.

Leaders at the service did not always support high quality care. Staff told us the registered manager was supportive and reactive to the needs of the people at the service. However, they felt the registered manager was not always given the resources needed. People at the service explained the registered manager was approachable and compassionate. We saw them interact positively with people at the service.

Some staff told us that they did not always feel their opinions were valued. This is because they raised concerns but action was not taken. People told us that they felt able to speak up and their voice would be heard. One person said, “If I have a problem, which is rare, the manager comes to me.” Staff knew how to encourage people to speak about any concerns.

The service valued diversity in their workforce and ensured equality and equity for people who worked for them. We saw that diversity was supported during recruitment processes, and staff were supported with adjustments in their work if needed.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Care plans were not always of the expected standard and governance systems has not identified or resolved this issue. We saw that there was an action plan for refurbishing the building, however the building still did not meet expected standards. The service had policies in place, however these were not always followed. For example, a policy guided staff to involve people in planning their care and record their involvement. This had not been applied in practice. At the last inspection, we found concerns about the governance at the care home. This is an ongoing concern at this inspection.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. We identified that three safeguarding referrals had not been made as expected. However, we otherwise saw there were clear processes to refer people to other services as needed. Staff were confident in these referral processes and understood how to work seamlessly with other professionals.

The service did not always focus on continued improvement across the organisation. We found some audits had occurred but not resulted in improvements. For example, care plans had been reviewed monthly, but staff had not always recognised where improvements were needed. This meant the reviews had not resulted in effective changes.

There had been a legionella site risk assessment in 2019. This found people were at risk of infection by legionella bacteria. In February 2024, the local authority visited the service, they were concerned that there was no evidence of action taken. When we visited in November 2024, the registered manager was still not aware what action had been taken to improve legionella risks at the service. We later found that the provider had resolved the risk. However, it was concerning that this improvement had not been clearly shared with the registered manager to demonstrate improvements that had been made to the service.