Biffins Care 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 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 at the service.

This service scored 62 (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.

The culture of the service was person-centred and the registered manager told us they promoted this by ensuring staff at the service recognised every person as unique. The culture of the service focused on recognising the people they supported as individuals. A member of staff told us “I love my job. I know the residents well and I have time to sit with them.” People’s relatives found the service to be person centred and caring, a relative told us, “They understand and love my relative.”

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.

There was a registered manager in post during our assessment, supported by a deputy manager. The registered manager told us they felt supported by the provider and they had regular contact with them.

The registered manager and deputy manager were visible within the service and staff told us they felt supported by them. Management was highly regarded by people’s loved ones. Relatives shared positive feedback about the leadership team, with one commenting, “The managers are brilliant, as are the other staff.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager told us they had an open‑door policy and encouraged people, relatives and staff to raise any concerns. They emphasised that staff would not be judged for speaking up and reinforced that everyone had a role in keeping people safe. Staff were able to discuss concerns during regular team meetings and through supervision. One member of staff told us, “The managers are very supportive, I can go to them with any issues or if I need help with anything. The provider is very approachable as well.”

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. The registered manager had a good understanding of the Equality Act. The provider employed a diverse staff team including different ethnic backgrounds and genders. The service had equality and diversity policies in place and promoted an inclusive and fair culture through training, staff had all received training in relation to Equality, Diversity and Inclusion.

The provider did not always have clear responsibilities, systems of accountability or effective governance arrangements in place. Although audits had been completed, they were not robust enough to identify issues or drive consistent improvement. As a result, key risks, such as environmental defects and stock control issues in medicines were not identified until highlighted during the assessment. This limited the provider’s ability to maintain a safe environment, ensure good practice, and respond promptly to concerns. While the provider acted once problems were raised, governance systems must be strengthened so that issues are identified proactively and improvements sustained.

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. The service worked collaboratively with other professionals and ensured that people had access to services they needed. Feedback provided from partners was positive, one professional told us, “The team demonstrates appropriate skills and experience in supporting residents with complex health needs. They engage well with healthcare professionals and are receptive to advice. Communication is clear and responsive, particularly regarding changes in residents’ conditions, medication queries, and safeguarding concerns.” People were supported to access the community if they wanted to, one person at the service told us they were supported to access the local shops.

The provider did not always maintain a consistent focus on continuous learning, innovation or improvement across the organisation and wider system. Staff were supported to develop their skills and were encouraged to work towards relevant health and social care qualifications.

Improvement plans were in place, but they had not been meaningfully updated. New or emerging concerns were not added, and actions from 2024 were still being worked through without reviewing whether they needed reprioritisation. This limited the provider’s ability to monitor progress and ensure improvements were completed in a timely manner.

During the assessment, we found the management team responsive to feedback and proactive in taking action once concerns were highlighted. They demonstrated a clear commitment to improvement, and since the assessment, the provider has created a new improvement plan and had already begun work on the most urgent areas. They assured us this plan will now be reviewed regularly so progress can be monitored and actions prioritised appropriately.