Bluebell Nursing Home

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 outstanding. 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 75 (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.

There had been recent changes in the management and senior staff team within Bluebell Nursing Home, and we received mixed views from staff in relation to staff morale. For example, some staff told us they felt some stress in relation to staff and management changes. However, a staff member said, “I think things are getting better, “I feel valued now, I didn’t a few months ago. I feel listened to by the management team and they are responsive.”

Discussions with the management team demonstrated they were fully aware of the recent issues in relation to staff morale and were working hard to address this. Actions taken included, increased management team visibility and staff engagement, arranging staff social gatherings and encouraging and providing staff with increased opportunities to share their views and ideas.

The provider had 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 did so with integrity, openness and honesty.

At the time of our assessment the manager in post had worked in the home for approximately 8 weeks and was planning to register with the commission. The provider was in the process of recruiting a deputy manager with a clinical background to enhance clinical oversite within the service. The manager was being well supported by members of the provider’s management team who were available and present in the home during our assessment visits.

Throughout the assessment the management team were open and honest. They demonstrated they were dedicated and passionate about their roles and wanted to ensure people had a good quality of life and received safe, effective and high-quality care. They were fully responsive to any issues or concerns we raised during our assessment and acted immediately to address these.

Feedback from staff members in relation to the overall running of the service included the following, “Since the manager and senior management team have been around, I think things have improved”, “I’m happy here, I feel there has been more support [from managers] recently” and “I like working here and am hopeful things will continue to improve.”

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

The provider had a whistle blowing policy in place and information about whistleblowing was readily available for staff reference as needed. Staff spoken with told us they felt able to speak up and they would be listened to. There was also an open-door policy which meant staff were welcomed to approach the management team at any time to discuss issues and concerns and to share ideas and feedback.

People, relatives and external professionals mostly felt able to raise anything with the management team and felt they would be listened to and action taken if required.

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.

There was a diverse workforce. The management team demonstrated a commitment to workforce equality, diversity, and inclusion and staff’s cultural heritage was respected. Staff undertook equality and diversity training, and we observed the culture within the service was one of equal opportunity.

The management team explained how they implemented workplace adjustments for staff, including accommodations for employees observing festivals and revised shift patterns to assist staff with personal and work life balance. This was confirmed by staff.

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.

There were mostly effective governance arrangements in place within the service. These were used to regularly check the quality of the service being provided and for the management team to know where focus was needed to improve standards. On review of the governance arrangements in place, we found the management team had identified some areas where improvements were required, such as the home environment. This had resulted in effective actions to be taken and detailed service improvement plans to be developed. This demonstrated the providers systems were effective and responsive. Additionally, the minor issues found on assessment, for example, in relation to repositioning monitoring were immediately addressed and action was taken to strengthened monitoring of repositioning records and pressure relieving equipment.

Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements.

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.

Peoples’ records showed the service worked closely with external healthcare professionals. This included using services such as, physiotherapists, chiropodists and hairdressers. An external professional told us, “Staff have supported [person] with their daily exercises, they are a very good team and communicate well with me and each other. They keep me up to date of any changes.” The service had regular communication and visits from local GPs to discuss any concerns or health queries. Staff also contacted GP surgeries outside of scheduled calls if they had any urgent requests.

Links with the local community had been created to enhance the lives of people living at the service. This included local groups linked to people’s specific faiths, a kids club, which involved local children visiting the home and visits from a petting farm as well as outings for people to the local community.

The views of people using the service, their relatives and staff were sought using both formal and informal processes including, face to face meetings, questionnaires and general conversations. Feedback was analysed and acted on.

Relatives were welcome to the home at any time and invited to partake in social events such as BBQs and parties. A face-to-face weekly support group had also been set up for relatives to provide them with a friendly space to talk, share or simply enjoy a cup of tea and some cake. Plans were also in place to invite relatives to specific workshops and training, for example a workshop was planned in relation to why people may require food and fluids at modified consistency and including detailed information in relation to food/fluid consistency, foods to avoid and food tasting.

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. They actively contributed to safe, effective practice and research.

The provider and management team showed a commitment to continuous improvement, with regular meetings and analysis of audits to ensure any learning had been identified, actioned and embedded.

Reflective meetings were held with staff to give opportunities to discuss development points to encourage improvement in practice. Learning was, where appropriate, also shared across the providers other services. The management team also arranged learning sessions and specific workshops for staff to improve their knowledge in some areas.

There was a detailed improvement plan in place which was continually monitored and drove improvements within the home.