Archived: Blakesley House 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 requires improvement. At this assessment the rating has remained requires improvement.

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 and person-centred care. The service was in breach of legal regulation in relation to good governance. The systems and process for checking the quality of care were not robust enough. Some staff were not able to explain safety procedures. There was a lack of activities. We were not provided with a service improvement plan. We could not establish how the provider promoted inclusion, diversity and equality. However, the staff we spoke with told us they felt supported in their role. People and relatives told us the home was well managed.

This service scored 61 (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 vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider did not provide any assurances around the culture or engagement of the service. It was difficult to establish the vision or purpose of the service. People and relatives commented on the lack of community engagement and in general the lack of meaningful activities within the home. This had not been addressed by the leadership team. However, people and relatives told us the staff were good and caring. People told us their needs were met. Following our visit the local authority reported that the policies and procedures had been reviewed and read by the staff team.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders had not ensured that medicines were administered safely. They had not picked up on concerns raised at this assessment. However, staff told us they were supported in their role. People and relatives told us they felt the home was managed well.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff told us they could raise concerns and felt they would be addressed. Information about whistle blowing was provided to staff.

The provider did not share information about their approach to equality and diversity, therefore it was difficult to establish how they promoted inclusion or diversity in the work environment.

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. It was difficult to establish what systems were in place for governance and quality assurance. Information provided by the provider was very limited. The information shared with the commission showed that audits of the quality of care did not pick up on concerns raised at this assessment, for example, the safe management of medicines. We could not verify what quality checks had been carried out by the provider. This meant concerns or errors may not be picked up and addressed in a timely manner. The lack of checking the quality of care could put people at risk of harm.

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. During our visit over 2 days we saw a very limited number of activities going on in the home. There were no links to the local community. People and relatives commented on the lack of both outdoor and indoor activities. However, the provider worked well with the local authority and health care professionals. These partnerships helped to ensure people’s care needs were met according to their care plan.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. We were unable to determine what system was in place for learning or improvement for the home. Following our visit the local authority confirmed that the provider had an improvement plan in place, and they were working towards completing actions in key areas such as quality assurance and care planning.