Brighton Lodge

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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 systems to assess and improve the quality of care and drive improvement were not effective. The provider had failed to ensure records were accurate and up to date. Care plans and risk assessments had not been updated to reflect people’s changing needs. Shortfalls in the safety and effectiveness of recruitment procedures and completion of staff training had not been identified by the provider’s own governance systems. These concerns resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

All staff told us they felt valued and supported by the manager. One staff member told us, “100 percent feel valued by the company and its management board, but most importantly my boss [registered manager’s name] has been an incredible manager. Often when things don't go to plan, they are always interested on what could be done better to enhance the quality of services provided for services users as this would enhance quality of life.” We spoke to the registered manager about the shortfalls we found during this assessment to understand what systems were in place that should have alerted them to these concerns. They informed us they have not been following their provider audit systems in place. They recognised that carrying out both roles as director and registered manager was having an effect and they were going to recruit a registered manager to support them. The registered manager did not assure us they knew when to submit notifications to CQC. The registered manager also confirmed they did not have formal processes in place to seek the views of staff or family members. We spoke to the registered manager about how they were going to make improvements going forward. They told us, “I haven’t sent any notifications to CQC but we do report them to the local authority. I need to look on the CQC website to make sure I am confident of what to report.” The registered manager was able to confidently tell us what they hoped to achieve for people and how they were meeting these aims and objectives. They told us, “I am going to ensure documentation is evidenced and that I follow the correct practice. I will educate myself on CQC website and I need to ensure I carry out audits with family members to get the feedback from families. Audit myself to ensure I am meeting good standards. That I inspect all application forms and take appropriate actions with the candidate especially in relation to gaps in employment and references. Look to recruit a registered manager.”

The quality assurance systems to assess and monitor the service were not always in place, and where they were, they were not effective and did not ensure that the fundamental standards were being met. The provider failed to ensure records were accurate and up to date. For example, we saw care planning documentation contained out of date information which meant staff did not have easy access to current information about people. We identified shortfalls in relation to staff recruitment, the completion of staff and supervisions and appraisals. There was a lack of systems and processes in place to seek and act on the views of people and staff. These shortfalls had not been identified promptly so that remedial action could be taken to improve the service for people. Standard operating procedures for staff to know how to support people who did not have capacity to make decisions about their care independently, could be more robust. Staff were supported by team meetings. We reviewed team meeting minutes for 22 September 2023, 20 October 2023 and 1 December 2023. We saw discussions took place relating to supporting people when distressed, health and safety, rota’s, medicines, signing sheets, training, recruitment, and the need for a consistent approach when supporting people. Following the inspection the registered manager was looking to recruit a registered manager to help keep records up to date and to ensure that effective quality systems were in place.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.