Burrow Down Residential 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 good. At this assessment, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, the need for consent, person-centred care, dignity, staffing and good governance.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The registered manager told us they promoted an open and honest culture, and information was shared with staff through daily handovers and regular team meetings. However, we found the service did not have a clear shared vision or a culture that promoted transparency, equity and inclusion. Staff were unclear about organisational values and reported inconsistent leadership support. While some staff described a “family‑like” atmosphere where they felt supported, others told us they felt unsupported by the senior management team. This inconsistency was not underpinned by effective systems or reliable communication. There was a lack of understanding across the service on how to meet regulatory requirements and deliver high-quality support for people with a learning disability or autistic people.

Provider oversight and governance arrangements were weak. Governance meetings lacked structure, and staff told us they did not always receive feedback or clarity about actions taken. Feedback from relatives highlighted concerns regarding poor communication and delays in addressing issues raised. One relative said, “Definite lack of communication back to parents.” Another said, “I have to ask for [Person name] to be taken to the doctors. They did take [Person’s name], but I got no feedback, so I have to chase them.”

We found a lack of insight and understanding from the registered manager regarding some people’s experiences of receiving support at Burrow Down Residential Home and the impact this was having on their quality of life. The registered manager was unable to recognise the extent to which the culture within the service had deteriorated or how this was affecting people’s day‑to‑day experiences. We discussed our findings with the new operations director and the provider, both of whom were unaware of the poor culture that had developed within the service and had taken no action to address it. This lack of oversight and proactive leadership contributed to continued poor practice and a failure to drive improvement. This contributed to a breach of regulation relating to good governance.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The registered manager and provider did not demonstrate sufficient oversight of the service to ensure people received care and support that always promoted their wellbeing and protected them from harm. They did not identify the concerns we found at this assessment.

The registered manager had received limited induction, and senior staff were unclear about their roles and responsibilities. Although some staff praised individual managers for being approachable, this did not translate into effective or robust leadership systems. Staff at all levels told us they felt unsupported, which contributed to inconsistent practice and a lack of oversight.

There was a lack of understanding within the service about how to meet regulatory requirements and deliver high‑quality support for people with a learning disability or autistic people. This contributed to a poor culture in which people were not consistently treated with dignity, respect or compassion. For example, care records contained limited information about people’s goals or future aspirations, and people were not sufficiently supported or empowered to exercise choice or control over their care.

The provider failed to use the resources available to them to support people and to develop staff knowledge and skills. For example, whilst the provider had brought in senior managers from its other service, Precious Homes, to provide management support. There was no evidence that the provider’s Positive Behaviour Support (PBS) Associate Practitioners had been engaged within the service. This meant opportunities to improve practice, strengthen staff competency and enhance outcomes for people were not being utilised.

Policies and procedures were in place, but they were not consistently followed. This included key areas such as safeguarding, care planning, risk management, medicines administration, application of the Mental Capacity Act 2005, and recruitment. This contributed to a breach of regulations relating to safe care and treatment, safeguarding, the need for consent, staffing, person-centred care, dignity and good governance.

People did not always feel they could speak up and that their voice would be heard.

The provider had policies in place to support staff to speak up, raise concerns and keep people safe. Staff spoke positively about the registered manager and deputy managers, telling us they felt able to raise concerns if needed. One staff member said, “Yes, [registered manager name] is a good manager and I find him approachable. [Deputy manager name] is lovely and I would go to either of them if I had a problem or needed to raise a concern.”

However, we found this was not consistently reflected across the whole staff team. Some agency staff were unable to describe what constituted abuse and were unsure to whom to escalate concerns. There was limited evidence of a culture that actively encouraged speaking up, and staff at different levels told inspectors when they had raised concerns, no action was taken. For example, a senior staff member told us they had informed their line manager they needed support, but no support was provided. This lack of consistent response created a culture where staff did not feel confident concerns would be acted upon, increasing the risk of poor practice going unchallenged. This contributed to a breach of regulation relating to good governance.

Relatives consistently told us they were able to speak up and raise concerns if something was not right. One relative said, “If you spot something wrong, they are keen to put it right.” Another said, “There are times when I have expressed a concern, and they took action to address them.”

The provider valued diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us the service did not tolerate bullying, harassment or discrimination. The staff team was diverse, with a mix of genders, ethnicities and backgrounds. Staff told us they felt welcome and accepted. However, we found gaps in how workforce equality and inclusion were supported in practice. International staff faced language barriers that affected communication with people and their relatives, and there was no evidence of structured support in place to address this. Staff reported feeling valued by their peers;however, they did not feel valued by the operations manager, the chief operating officer, or the owner. We saw no evidence of reasonable adjustments or proactive diversity and inclusion initiatives to support the workforce. The lack of oversight and poor staff support provided to the registered manager and deputy manager had a direct impact on the quality of care and supportprovided to people using the service. This contributed to a breach of regulation relating to person-centred care and good governance.

Policies stated recruitment decisions would not be based on ethnicity, sexual orientation, age, race, gender, disability, gender reassignment or any other protected characteristic. Staff were required to complete equality and diversity training. However, not all staff had completed this training, which increased the risk of discriminatory practice going unchallenged.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

Governance systems were ineffective and failed to identify, manage or address significant risks within the service. Audits were inconsistent, and quality assurance processes did not reflect day‑to‑day practice. Care plans and risk assessments were not updated promptly, and oversight of medicines management, finances and environmental safety was poor.

Governance processes could not be relied upon to keep people safe, protect their rights and did not effectively monitor quality, manage risk or drive improvement. Changes in leadership and a lack of managerial support contributed to systemic failings found at this assessment. This contributed to a breach of regulation relating to good governance.

The provider and registered manager understood their responsibilities in relation to the duty of candour. Duty of candour requires providers to be open and transparent with people who use services and other people acting lawfully on their behalf in relation to care and treatment. However, systems had not been effectively operated to identify and report significant events. This had led to the provider not notifying the Care Quality Commission of 4 significant events in line with their legal responsibilities. This was a breach of regulation in relation to notifying CQC of significant events.

Following the inspection, the provider confirmed action had been taken to strengthen oversight and support the day-to-day management of the service. These measures were intended to address the concerns identified and improve the quality and safety of care provided. The provider was working with the local authority to address all aspects of service delivery and drive improvements across their services.

The provider did not always collaborate or work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager recognised the importance of working in partnership to improve people’s outcomes. They described how they worked in close partnership with people, their families where appropriate, and the local authority to achieve good outcomes for people. Records showed staff worked with healthcare professionals, including GPs, district nurses, and the Learning Disability Intensive Assessment and Treatment Team (IATT), to support people.

The staff approach to partnership working was inconsistent. Feedback from relatives highlighted poor communication and limited involvement in care planning, and there was little evidence of structured partnership working to improve outcomes for people. For example, clinical advice was not always followed, and staff were slow to escalate concerns or seek professional guidance when required. While some people were supported to access community activities, opportunities were restricted due to staffing shortages and a lack of effective transport planning.

We also found no evidence of meaningful engagement with people or their relatives to inform service development or shape the direction of the service. This contributed to a breach of regulation relating to good governance.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not demonstrate a culture of learning or continuous improvement. Lessons from incidents were not embedded, and risk assessments were often created reactively rather than proactively. There was no evidence of a systematic review of care plans following incidents, and audits failed to identify gaps in practice. Staff reported limited training and no reflective practice sessions. Innovation was absent, and improvements were largely driven by external intervention rather than internal governance. There was no evidence of proactive planning or sustained improvement.

Concerns and complaints were not consistently investigated or acted upon promptly, which limited opportunities to identify learning and drive improvements in the quality of care and support provided. Feedback was not routinely sought from people, relatives, staff or other health and social care professionals, and was not used as a mechanism to support development or service improvement. This failure contributed to a breach of regulatory requirements relating to good governance.

Throughout the assessment, the registered and deputy managers were open and honest, acknowledged the areas requiring improvement and demonstrated a commitment to addressing concerns and improving staff practice. The nominated individual and owner also apologised for the poor standard of care provided and assured the Commission they would use our feedback to inform a comprehensive service improvement plan, strengthen the culture within the service and improve governance arrangements.