Burnt Tree Croft

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 service was in breach of legal regulation, in relation to governance.

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 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. Managers highlighted their goals for the service during the assessment. Staff told us that leaders collaborate with them about the learning and improvement of the service. One staff member told us, “We are always kept updated with any changes, and are told about them often.”

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. Staff told us that the manager at the service had the appropriate skills, knowledge, experience and credibility to lead effectively. Staff told us managers led by example and were visible in the service. One staff member told us, “[Managers] are hands on within the team, they become involved and support staff where we need it. They always have the time to help us [staff] in any way they can.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Regular staff meetings were held and evidenced the opportunity for staff to speak up and drive improvements. One staff member told us, “I know how to whistle blow if I felt concerned about anything, and I know [managers] would listen and take action.”

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. Staff told us that they were treated fairly and equitably and had the confidence to speak up if they had any concerns about the service. One staff member told us, “I always feel listened to. Their [manager’s] door is always open.” There was also evidence of implementing reasonable adjustments for staff who required them.

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. The provider had failed to robustly assess and manage risks posed to people relating to Infection Prevention and Control (IPC), and the environment. There was a lack of urgency in relation to the concerns being addressed within the service. An audit had identified multiple IPC concerns. However, we found these concerns had still not been addressed, and it could not be evidenced plans were in place to rectify these issues. Health and safety audit’s failed to identify issues we found in relation to window restrictors and other environmental concerns. Although we found no harm to people, we also found concerns in relation to the safe management of medicines, there was a lack of effective systems and processes in place to ensure people received their medications safely, and as intended. In relation to the effective management of Asbestos, the control measures outlined within the assessment were not appropriately managed.

The provider did not always share information and learning with partners or collaborate for improvement. The concerns in relation to the services Infection Prevention and Control, highlighted the need for engagement with external parties. This involvement was offered to the service previously and could have benefited the service’s safety and development if engaged with.

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. Quality assurance systems and action plans were not robust and required improvement to evidence continuous development within the service.