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 continued to be 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.

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.

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. Staff told us they felt able to speak up and they would be listened 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. Staff told us leaders were inclusive and fair towards staff.

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.Some improvement had been made since our last inspection however, systems for governance and oversight required further strengthening and embedding into practice.

While audits were being completed, they were not sufficiently robust in identifying key areas requiring improvement. The audits failed to identify the issues we found during the inspection.

Medicines audits had not identified several key risks. Medicines rooms were not consistently maintained at safe temperatures, and actions had not been taken when temperatures exceeded recommended levels. There were no protocols in place for some PRN (as-needed) medicines, and expired medicines awaiting disposal were found in stock. These issues had not been identified through routine audits, demonstrating a lack of effective oversight in medicines management. The registered manager was receiving ongoing support from experienced managers and quality and compliance partners to strengthen governance arrangements.

The provider did not always share information and learning with partners or collaborate effectively to drive improvement. Information from external partners, including where people were discharged from hospital, had not been accurately communicated within the service. The provider’s governance systems failed to identify this, resulting in shortfalls in the safe administration of medicines. These systems needed to be improved to ensure similar occurrences are prevented in future.

The provider did not always focus on continuous learning, innovation, or improvement across the organisation and local system. They did not consistently encourage creative ways of delivering equality of experience, outcomes, or quality of life for people. Quality assurance systems and action plans were not robust and required improvement to demonstrate continuous development. Although the provider had offered further support to the service, this needed to be sustained and used to drive ongoing improvement to ensure consistent progress over time.