Bramcote Hills Care Home

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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

We assessed 7 quality statements in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection. There were not effective governance, management and accountability arrangements. Management did not understand their role and responsibilities. Managers did not have oversight of the actions, behaviours and performance of staff. The systems to manage current and future performance and risks to the quality of the service did not take a proportionate approach to managing risk that allows new and innovative ideas to be tested within the service. There were not robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was not used effectively to monitor and improve the quality of care. Leaders failed to implement relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes. Data or notifications were consistently submitted to external organisations as required.

This service scored 25 (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 aware of what the shared culture or direction was within the organisation. Staff at all levels failed to understand the importance of considering individuals equality, diversity and human rights in order to promote and develop a positive culture.

The provider failed to ensure there was a shared vision and strategy in place that allowed people and staff to understand the direction of the service taking into account equality, human rights and inclusion. There was no process or system in place to understand or promote a positive culture or understand the community that was using the service and working at the service. The provider failed to ensure they provided management and staff with appropriate training in equality and diversity. This meant staff at all levels were not equipped to foster an understanding and appreciation of equality, diversity, and human rights or promote an inclusive culture where all individuals were treated with respect and dignity.

Staff did not feel the management team were capable. One staff member told us, “Staff have told management that more staff are needed. If something is missed out due to pressure and rushing about, staff get issued with a ‘Discussion form’ which can lead to disciplinary. It seems unfair as if there were more staff then things wouldn’t get missed or errors made as it would be less stress.” This meant that management were not capable or compassionate to ensure people received safe and quality care. The management lacked an understanding of ensuring that they were inclusive leaders. Management could not explain how people living at Bramcote Hills Care Home, those who were important to them or staff were involved in a meaningful way regarding care planning, feedback on the service or made aware of how to raise concerns. The management team could not explain what systems and processes were in place to enable feedback on the service. People had raised concerned about the service; however no action was taken by management to address the concerns, especially around staffing levels.

The service was not well-led. The provider failed to ensure there was a management team that was capable or compassionate. The management team including the registered manager had worked for the provider for a long time. However, the management team lacked knowledge and skills to ensure the service was managed safely. They failed to ensure people always received safe care and treatment. Roles and responsibilities were not clearly defined to ensure each level of management and senior staff were aware of their role. The provider and management team lacked skills and knowledge. The concerns and risk we identified had not been identified by the provider due to poor oversight of the service. 'When concerns regarding safe staffing levels had been raised, the provider and management at each level had failed to take appropriate action. This meant people were left at risk of harm.

We received mix feedback regarding freedom to speak up. Some staff told us that they felt management were approachable. However, other staff raised significant concerns not being able to speak up. Staff told us they did not feel confident to raise concerns confidently without being blamed or treated negatively if they did so. One staff member told us, “Staff have told management that more staff is needed, but now If something is missed out due to pressure and rushing about, staff get issued with a ‘Discussion form’ which can lead to disciplinary. It seems unfair as if there were more staff then things wouldn’t get missed or errors made as it would be less stress.” Staff were not confident in using whistleblowing processes if they felt concerns was not being responded to. Staff told us they had not been provided with the whistleblowing policy. One staff member told us, “If there were to be a need to whistleblowing, I would ask a manager what to do. I have not been told what the procedure is or who to approach. Staff do not have much to do with the managers or area manager as they are not often accessible as in, at the home.” This meant people were not provided with the right information to enable them to speak up. The management team told us they have an open-door policy, so staff can raise any concerns. However, during our onsite assessment it was clear that due to the insufficient staffing levels management would be supporting people and not have the time to listen to staff feedback. We were therefore not assured this system was effective.

The provider failed to ensure systems were in place that acted with openness, honestly and transparency with staff and people living at Bramcote Hills Care Home. The provider failed to empower staff to raise concerns to allow a system to drive improvements and enable safe care and treatment. The provider failed to ensure that there was not a closed culture. For example, there was no processes or system to allow staff and people living at the care home to actively raise concerns without fear of detriment. The provider failed to ensure when concerns were raised, there was a clear process to record, investigate and put measures in place to drive the required improvements. The provider did not ensure that there was a culture of when things went wrong people received a sincere and timely apology and were provided with information on what actions were being taken to prevent the same happening again. For example, we received incidents and accidents where there was no record of ensuring the duty of candour was followed.

Staff told us the management team, or the provider had not taken any action to monitor, review or improve the culture. Staff were not aware if there was a policy in place to ensure equality and inclusion across the staff team. Care assistance staff were not provided with opportunities to be included in decision making or be asked about their opinions. Staff did not raise any concerns regarding discrimination. Staff had raised concerns for staff whose first language was not English, staff felt they had not been provided with any support to ensure they understood people’s needs and the systems and processes within the home.

The provider failed to ensure there was effective and proactive ways to engage with and involve staff. For example, the provider did not have a focus on hearing the voices of staff with protected characteristics and those who could be excluded, marginalised or least heard within the care home. The provider made no effort to ensure all staff felt empowered and were confident that their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation. The management team did not have staff team meetings or one to one supervision to allow staff an opportunity to contribute to continually reviewing and improving the culture of the organisation in the context of equality, diversity and inclusion.

The management team told us there was a registered manager and a second manager supporting. They told us they both were responsible for the management of the care home to ensure it met the regulations. However, the managers did not have clear roles and responsibilities. There was confusion over whose role it was to carry out audits and consequently take actions following these audits. We asked to see the management audits and the only audit the management completed was on care plans. This meant the management team and the leaders failed to ensure there was an oversight of the service to ensure risks and concerns were identified and action taken.

The provider failed to ensure the management team had clear responsibilities, roles, systems of accountability and good governance. We found no culture or system in place to manage and deliver good quality, sustainable care, treatment and support to people living at Bramcote Hills. The provider consistently failed to act on the best information about risk, performance and outcomes, and failed to share concerns and risk securely with others when appropriate. For example, we found the management team failed to identify people consistently had received poor quality care, even when staff raised their concerns. The provider did not have effective systems and processes in place to ensure there was effective oversight to monitor the performance and quality of the service. This meant the provider missed opportunities to identify risks we found during our assessment of the service. The operations manager had completed an audit in March 2024 and we found the actions were still outstanding with no clear plan in place for when the risks that had been identified would be actioned. We were not assured the provider, or the management team had the skills and knowledge to understand risks and how to manage risks to deliver good quality care.

People did not have access to regular health checks such as dentist, opticians or chiropodist. This meant people did not have access to community health services or provided an opportunity to work collaboratively with other health partners.

Staff and management told us they worked collaboratively with partners to ensure information was shared with partners. However, feedback from partners did not show this was always effectively done.

Health professionals had told us prior and during our onsite assessment that there was room for improvements. The provider did make health referrals when needed but did not always follow the advice to ensure people received appropriate care. 'For example, a dietitian had raised concerns of when a persons' glucose levels were taken and recorded. During our onsite visit and after our visit there continued to be a failure to follow health professionals care plans.

The provider did not have systems or processes in place to ensure there was effective communication between the care homes management team and other professionals. For example, professionals raised concerns regarding the poor communication between the care home and them. The provider had failed to ensure that information recorded about people was not always up to date, accurate or sufficiently detailed. This meant that people could have been at rick of not having up to date and accurate information shared about people them between professionals.

Staff told us the management team were not competent and did not listen. One staff member told us, “Staff have given their concerns to the seniors, they have escalated to managers. we would have expected a staff meeting or something with the managers to talk about it but there has been nothing. No information from management at all, so seniors have had nothing pass back to us.” Staff told us there was no learning culture from the management team to want to improve or innovate. Staff felt they were not listened to when they had raised concerns and made suggestions to improve the quality of care people were receiving. The management team were unable to explain what learning they had completed since our last visit. The management told us they did not have any plans in place to make improvements as they thought they offered a good service. The management team told us they were considering moving onto an electronic care planning and recording system in the future.

We found there was not a culture of learning lessons when things went wrong. We told the provider the concerns we found during assessment. The local authority carried out safe and well checks after our visits and had highlighted the same concerns we found regarding, staff levels, poor record keeping, poor risk management, ineffective debriefs leading to a lack of learning, and good governance. We returned to the service on 23 July 2024 and continued to find similar concerns and risks we found on day one of our assessment. This placed people at risk of continued poor practice. There was no governance process, system or culture in place to reduce the number of incidents and ABC (antecedent, behaviour, consequence) incidents. The Registered manager did not have an oversight of the incidents and ABC incidents. There was no audit completed by the management. The inspector was told the team leader should review all ABC records, incidents and accidents at the time of the incidents. This meant there were not a robust system and process in place for incident and accidents and subsequent learning on how to prevent incidents in the future. This placed service users at risk of incidents reoccurring. The service did not have an effective system of quality monitoring to identify where areas of the service required improvement'. There were no systems or processes in place to actively seek the views of a wide range of service users, this included people using the service, staff, professionals and relatives.