Burnside Court

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 remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 57 (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 did not have a clear, shared strategy to guide service delivery.

The business contingency plan lacked detailed instructions for certain emergency situations. For example, the service relied on an electronic care planning system, but the contingency plan did not include clear guidance on what to do if the internet failed. This meant management and staff did not always have access to up-to-date information to support people safely.

Despite this, the registered manager promoted a shared vision and culture based on transparency, equity, equality, human rights, diversity, inclusion, and engagement.

The provider had inclusive leaders who understood the context in which care, treatment, and support were delivered, and embodied the values and culture of the workforce and organisation. Throughout the assessment, the registered manager was open and honest.

The registered manager was visible within the service, and staff told us they were approachable. The management team was stable, with senior staff and leaders having worked at the home for some time.

Relatives told us the service was well-led. Comments included, “Yes, definitely,” and “Absolutely.”

While we received positive feedback about the management team, this assessment identified issues that led to breaches of legal regulations which had not been identified by the provider.

The provider fostered a positive culture where people felt able to speak up. However, some relatives told us that although they could raise concerns, they felt their voices were not always heard.

There was a complaints and whistleblowing policy in place. Staff told us they felt confident raising issues with the management team.

We observed the registered manager operating an open-door policy for people, staff, relatives, and professionals, encouraging open communication and promoting a culture of trust, collaboration, and transparency.

Relatives told us the registered manager was approachable. Comments included, “We can have a chat with (Registered manager’s name) or send an email or go to a relative meeting,” and “They have a WhatsApp group and we can raise any issues that we need to.”

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 registered manager told us they operated a zero-tolerance approach to discrimination, bullying, and harassment within the service.

A staff member told us, “I do not feel there is any discriminatory behaviour taking place, but feel that the manager would be very supportive.”

The provider did not consistently maintain clear responsibilities, role definitions, systems of accountability, or effective governance. They failed to act on reliable information about risk, performance, and outcomes, and did not always share this securely when appropriate.

The registered manager lacked oversight of people’s daily care records, which meant the provider could not be assured care was delivered in line with assessed needs. For example, a person’s assessed needs of needing support with 4-hourly mobility support was not always being provided.

Although systems had been introduced to improve recruitment, they did not identify some staff files lacked a full employment history. As a result, the service did not consistently meet the Schedule 3 requirements under the relevant regulation.

Systems and processes were not robust enough to identify the shortfalls found during this assessment, particularly in relation to care planning. While care plans were reviewed, the process was not effective in ensuring staff had access to the most current and relevant information about people’s care and treatment.

The registered manager did not have an embedded process to monitor staffing levels required to deliver the regulated activity.

There was no evidence of provider oversight or involvement in the service’s quality assurance processes.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach in relation to governance.

The provider understood their duty to collaborate and work in partnership.

Improvements had been made since the last assessment. Identified weight loss had been shared with relevant professionals.

The registered manager maintained effective working relationships with external partners, including the local quality team and mental health services.

Statutory notifications were submitted to the appropriate bodies, in line with legal responsibilities.

A professional told us, “(Registered manager’s name) has worked well with me over COP (Court of Protection) referral/ report and monies.”

The provider did not consistently promote continuous learning, innovation, or improvement across the organisation. They did not actively contribute to safe, effective practice or research.

The registered manager completed an action plan following audit findings, but identified measures were not always implemented. Opportunities to improve the quality and safety of the service were missed.

Some improvements had been made since the last inspection. However, further action was needed to ensure compliance with legal requirements under the Health and Social Care Act 2008, as outlined in this report.

Whilst we did not identify anyone had come to harm, this contributed to the continued breach in relation to governance.