Burnham 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

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 assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff spoke positively about the management team. The senior leadership team were supportive, knew staff well, and provided opportunities for them to be recognised for their achievements and the care they delivered.

Staff were provided with a comprehensive onboarding programme, which included face to face induction sessions with senior leaders. The registered manager further supported this by providing “flashcard packs” that staff carried round. These packs contained details of the provider’s shared vision, aims, and important information around care standards such as safeguarding, whistleblowing, accessible information standards, and a quick guide to using the electronic care planning system.

Staff told us, “My workplace has friendly, caring, loving environment and teamwork”, and “It’s a real team effort where everyone’s contribution is valued to make our home a caring community.”

This meant that staff culture enabled people’s care to be safe, kind and respectful.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Leaders demonstrated high levels of capability, compassion and inclusivity. People, relatives, staff and external professionals consistently praised the registered manager. We observed visible, approachable and skilled leadership that set clear expectations for high‑quality, person‑centred care. Leaders had clear lines of responsibility and accountability, and information was communicated across the staff team well.

We observed the leadership team speaking with every person, visitor and professionals they met, always introducing themselves where needed, and asked after people’s wellbeing.

Leaders were visible throughout the home, assisting with daily care tasks where specifically requested by people themselves, and supported activities.

People knew the management team and were positive about their experiences with them. People told us, “’I’ve seen a manager, I’ve seen [them] this morning. There are different ones and they all come in and show themselves”, and “[Registered manager] is brilliant, [they are] always interested.” Relatives expressed similar feedback. Comments included, “We know that if we have any concern or problem that [registered manager’s] door is always open”, and “The manager is open and I can raise anything with [them].”

Leaders modelled flexible, person‑centred working practices and prioritised staff wellbeing. Staff spoke with pride about working within the service, describing leaders who were visible, approachable and genuinely invested in their development.

Staff told us, “[Registered manager] is great. [They] always ask us how we are and if we need anything”, and “I feel fully supported by management to lead these changes and keep our standards high.” This reflected a workforce that felt inspired and sustained by capable and inclusive leadership.

Leaders demonstrated professional competence and oversight. The registered manager described a robust programme of audits, daily dashboards and routine oversight of care records, medicines and incidents. We observed the registered manager communicating well with the staff team during our visits, responding to feedback we gave promptly.

The combination of skilled oversight, compassionate relationships and inclusive team culture demonstrated outstanding leadership that directly contributed to positive outcomes for people.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had an open and supportive culture where staff felt able to raise concerns and contribute to improvements. Staff consistently described managers as accessible and responsive showing confidence that issues would be addressed. Staff told us they were able to attend handovers and staff meetings where concerns or learning could be discussed, and changes occurred as a result, for example, “Care plans are updated, new procedures are implemented, or improvements in day-to-day routines are agreed upon based on feedback from staff and management.”

There were appropriate policies in place to support safe reporting, including a whistleblowing policy with alternative external routes for staff who felt unable to raise concerns internally.

People and relatives also felt comfortable raising concerns, telling us “If I’ve got anything to say, I’ll say it to [registered manager] or [administrator]”, and “You can always go to them if you want any help. All my family get on well with them.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had implemented several measures to ensure staff were treated fairly, supported appropriately, and able to work in an inclusive environment. Staff were offered a culturally appropriate meal provision when at work and a structured leadership development programme.

Staff had access to a buddy and mentoring system during their induction. The service championed neurodiversity and made adjustments to the onboarding process for staff who identified as neurodiverse. These initiatives strengthened leadership capability and contributed to improved staff retention.

Staff told us they felt well supported by management to carry out their roles. Comments included “I feel supported, I feel like I have a wonderful workplace”, “staff morale is overall good”, and “[Registered manager] is great, you can go to [them] for everything, even if [they] don’t have it in [their] power, [they] will make sure [they] get it.” A staff member also told us “I feel fully supported by management to lead these changes and keep our standards high. It’s a real team effort where everyone’s contribution is valued to make our home a caring community.” This meant that staff felt valued and were happy in their workplace, resulting in a positive atmosphere for people.

A person’s relative told us, “I think they’ve improved greatly over the last 12 months. There seems less turnover and use of agency staff and more stability of carers, nurses and management and it seems to be a happier place to work."

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had effective governance systems, with responsibility for audits allocated for accountability across different staff teams, and this was overseen by the managers.Governance arrangements were embedded, and we observed a clear improvement in the quality of audits carried out over several months. The registered manager carried out audits on a monthly schedule. These included medicines, care plans, IPC, falls, mealtime experience, call bells and safeguarding.

Call bell monitoring and audits were carried out regularly, some demonstrated that people sometimes waited over 5 minutes for a response. Records evidenced that the registered manager had taken action to resolve this, including a change in how staff responsibilities were allocated when on shift. All monthly audits reviewed were dated and complete, although actions were not always immediately clearly noted on the audits themselves. However, we observed learning communicated with staff in meetings about audits undertaken. This showed responsive oversight and effective use of audit processes to maintain standards.

Audits identified inconsistencies in care plans, for example, pressure injuries were graded differently in different areas of a person’s care plan. Audits did not identify that daily records were not always complete, for example, some repositioning records were not present. However, staff demonstrated a good working knowledge of people’s current health needs, and we did not identify any deterioration or harm caused.

The provider 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.

Records showed regular engagement with professionals regarding people’s care, collaborating with partners for improvement, and organising extra training to support staff to adapt the service to meet people’s diverse needs. An external professional told us that they requested the service provide care to another person they worked with, “as I know that [they] will be well cared for.”

The activity coordinators for the service had linked up with community groups to enable people to access further opportunities for hobbies and activities, such as football, religious services and reunion meals. This meant people’s care was delivered in a joined-up way and benefitted from a multi-disciplinary approach.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people by inviting staff to share new ideas to deliver effective, safe and responsive care. Audit actions were picked up in a service wide improvement plan, which was reviewed on a regular basis by the registered manager, to foster continuous improvement.