Burgess Care

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 governance at the home.

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.

Interim managers were leading the home at the time of the inspection, owing to the registered manager’s absence from the home.

Relatives had varying views on the culture at the home, with some advising staff were welcoming. However, other relatives told us staff did not communicate with them openly or work together to focus on their family member’s needs. One relative said, “It is toxic, to be honest. I can only think back to my own working experience, and there’s usually a warmth between the teams, but I never see it [at Burgess Care].”

Staff told us there were divisions across the staff teams, which meant people’s support was not given in a consistent way. Staff told us they had not been supported by senior staff when they tried to address this.

The poor culture did not demonstrate respect or dignity for people. For example, staff showed they regarded Burgess Care as their workspace, rather than people’s home, by storing their personal belongings in communal lounges and kitchens. During our inspection we saw external contractors walking in groups into people’s bedrooms and personal spaces without knocking or introduction and not being challenged by staff or leaders. This demonstrated people’s feelings or opinions were not valued or respected and they were not in control of who came into their home.

Interim managers acknowledged the culture of the home needed to be improved.

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, and they did not do so with integrity, openness and honesty.

Relatives raised concerns about the lack of leadership at the home, and reported senior staff did not always make themselves available when they wished to discuss their family member’s care.

Risks to people and the premises were not managed well. Staff told us they had previously raised concerns about staff practice, resources, equipment and the premises, but these concerns had not been addressed promptly. One staff member told us, “I have raised all of these concerns with the managers who don’t enforce anything. Staff get away with it as there are no consequences.”

Relatives and staff told us the provider and managers had not always been visible at the home.

There had been a lack of oversight from the provider and managers which meant they were not alert to examples of poor culture which may affect the quality of people’s care and have a detrimental impact on people. The lack of oversight also meant the provider and managers were not alerted to issues and priorities for the safety and quality of services in a timely way, so they could be addressed promptly.

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

Some staff had only been given limited opportunities to raise their concerns, as staff meetings were infrequent and some staff did not have regular supervision meetings. We found some staff did not understand how to whistle-blow and what protections were in place, and what processes they should follow if they needed to whistle-blow. Whistleblowing is the act of a worker reporting wrongdoing, illegal activity, or unethical conduct inside an organization to an authority or the public. The report must be made in the public interest rather than as a personal complaint.

However, other staff described a clear management structure and told us they would feel confident to initially share any concerns or feedback with their team leaders. They told us they would escalate their concerns through the management structure if they felt they needed to.

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

Some staff raised concerns about how fairly they were treated at work and told us this was not always resolved promptly. One staff member told us this led to an inequitable workload for staff. The staff member said, “Staff are frustrated, when nothing is done, when other staff refuse to do things. It’s not fair.” Another staff member commented, “I think I am treated fairly, but my emails are not always responded to.” They told us they had required support with communication when they first joined Burgess Care, but the provider did not offer this initially. The staff member confirmed the provider was now supporting them to access extra help related to this.

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.

Relatives advised us they had experienced increasing concerns about the way the home was run. One relative said there had been a deterioration in the care provided in the previous 12 months.

Throughout this report, we have identified significant concerns regarding the safety and quality of care provided, as well as the overall management of the home.

The provider's governance and oversight systems were not robust or effectively implemented to ensure risks were consistently identified and addressed in a timely manner. Monitoring processes had not always resulted in prompt action to meet people's needs, and concerns regarding the culture of care had not been identified and addressed without delay.

Some governance processes, such as the “Environmental Walkaround”, had only recently been introduced and had not yet had sufficient time to become established or demonstrate effectiveness. Some of the issues we found and were told about happened over a sustained period of time. No effective checks, oversight or action had identified or resolved these issues. A failure to identify and drive improvement had put people at unnecessary risk of harm.

The provider had also failed to ensure their policies and procedures were consistently followed across its services. This resulted in inconsistent practice in key areas, including risk assessment, care planning, risk management, and fire safety arrangements, such as the completion and implementation of personal emergency evacuation plans (PEEPs).

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

Relatives did not always feel they were partners in their family member’s care. Some relatives told us communication with senior staff was not always effective, and the outcome of concerns they raised were not always communicated to them. Relatives told us they were not always kept informed of the outcomes of their family member’s appointments with other services.

Some relatives did not feel listened to despite completing surveys to share their views about the care provided. One relative told us, “If you’re going through a social worker something might happen, but direct to Burgess Care nothing happens.”

Other health and social professionals told us partnership working was generally effective once contact was established with staff. However, telephone accessibility was inconsistent and appointments were sometimes missed.

However, some relatives told us there had been some improvements in communication, following the appointment of interim managers and staff gave us examples of occasions where joint working with other professionals had been more effective, to meet people’s needs.

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.

Systems for taking learning from incidents and safeguarding concerns were not operated effectively at the home. The lack of effective provider oversight meant shortfalls in consistency of recording and learning at the home had not been promptly identified or addressed. The checks undertaken at the home had not been robustly done and whilst more robust checks had been introduced recently by interim managers, these will take time to embed so opportunities for learning are maximised. Relatives and staff told us of a negative culture which meant they did not feel confident any concerns raised would be heard or acted upon. As a result, poor practice had become accepted as normal, and opportunities to learn important lessons and address these issues were missed. Consequently, necessary improvements were either delayed or not implemented.