Bryony Lodge

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

We found one breach of the legal regulations. The service did not consistently have adequate management oversight and there was no registered manager in post. The operations manager and the director visited the service once a week. The staff were responsible for the day to day running of the service on the days that the operations manager and director were not on site. However, the staff were able to contact the operations manager if they required assistance. The operations manager had completed quality audits, although they did not always identify shortfalls. An action plan was in place. However, actions were not always reviewed and progress recorded. The provider was responsive to our concerns following feedback and made improvements, but these were not yet embedded.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us the culture of the service had improved and the team all worked well together. They told us they all wanted the best for the people who use the service. Initially, staff told us they felt supported by the operations manager and director, but they felt they needed a manager to be available on site more regularly. The operations manager told us the culture in the service was poor last year and they had taken actions to address this. There was a new team in post and a new manager had been recruited. The new manager was in post at our final visit and staff told us they felt supported and the manager was approachable and helpful.

The provider did not always provide effective oversight and initially there was not a manager in post. The operations manager and director visited the service once a week. This lack of management presence increased the risk of staff not working together and placing people at the risk of harm. Staff had regular team meetings and regular supervision with the operations manager. The provider was responsive to our concerns and took appropriate action. There was a new manager in post, and they told us her plans for the service. At our final visit we observed the manager working with staff, providing information and role modelling.

Initially, staff did not have effective leadership. This was due to the operations manager and director only being in the service for one day a week. The remainder of the week there was no management oversight. A new manager was recruited and begin working at the service during the assessment. The new manager was responsive and had started to make improvements. The manager demonstrated they had knowledge and experience managing similar services. The manager was coaching the team and role modelling, They were working with the operations manager and director to make necessary improvements and develop the service.

The provider has robust policies and procedures. However, these were not always followed. Initially, the service did not have a manager in post and the operations manager and director visited the service once a week. There was not effective oversight of the service and identified concerns had not always been addressed. The new manager started working at the service and worked responsively with the operations manager and director to make improvements.

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.

The operations manager told us that the previous management team were not effective. The operations manager had completed audits. However, these had not always identified shortfalls. The operations manager was already aware of some of the concerns we raised during the inspection. There was a development plan in place and work was being completed to contact professionals to obtain essential information to create robust risk assessments and support plans. Staff told us they felt supported by the operations manager and the director.

The provider had robust policies and procedures. However these were not consistently followed. The provider had audits in place and the progress of required actions from the audit was being monitored by the operations manager. Initially, some of the concerns we found had already been identified by the provider and were included in the provider’s action plan for the service. However, we identified concerns that the provider was not aware of. These included the safe monitoring of people with epilepsy, fire evacuation and inconsistent and/or out of date information in people’s care plans and risk assessments. The provider’s actions were not always completed in a timely fashion and some actions identified by the provider had not been addressed for several months after they had been found. Initially, the service did not have a registered manager in post and lacked management oversight. The new manager was in post at the time of our final visit. The manager along with the operations manager and director were progressing with actions needed to improve the quality of the service. The operations manager was able to demonstrate improvements were being made. However, these needed further time to be fully embedded to fully assess the impact on the service.

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.