Burleys Wood

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.

This service scored 54 (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.

Staff raised concerns regarding the culture as they felt unable to speak up. Staff were approachable and cooperated with the inspection process. However, many care staff expressed a reluctance to provide feedback regarding the service. They expressed concerns about repercussions. One staff member provided feedback which included, ‘Please would you confirm that any concerns and issues raised will be strictly confidential as staff are worried details will be shared which will make things very difficult for people at Burleys Wood.’ Another staff member said, ‘I do hope this stays confidential as things will be made very hard for me at work.’ A third staff member said, ‘I can’t say anymore. I don’t want problems.’

Following the assessment, we discussed the feedback received from staff with the provider. The provider told us, ‘Being an Employee Owned Trust we really do value our employees voice and feedback which is why we have so many mechanisms in place for feedback such as, open door policy, suggestion scheme, whistleblowing, supervision /appraisal, anonymous employee surveys, unannounced independent compliance audits and we are disappointed that the staff felt they could not utilise any of these channels that are freely available.’ The provider gave examples of actions Shaw Healthcare had taken in response to our feedback. This included mechanisms they had put in place to facilitate further staff feedback (both anonymously and not). They told us, ‘In response to the feedback received, we arranged for the Head of Recruitment and Sponsorship Lead, Employee Voice Manager and the HR representative for the region to attend the service to offer wellbeing clinics, feedback sessions and catch ups.’ The provider told us, ‘[Their] findings were similar to the areas raised.’ They gave assurances they would take action regarding the feedback from staff.

Throughout the inspection, the registered manager demonstrated a good knowledge of the people living at Burleys Wood. It was evident they wanted to provide a good quality and person-centred service. However, staff gave mixed feedback regarding the registered manager and management team. A staff member provided feedback which included, ‘The company’s policies and intentions are not the issue. The failures stem from the manager’s poor leadership, lack of accountability, and unwillingness to address staff concerns. Staff morale is extremely low.’ They also said, ‘The staff representative is closely aligned with the manager and does not escalate staff concerns to head office for necessary actions. Thus, the company’s senior leadership are not aware of the true situation within the home; this hinders staff from having a true voice.’ Another staff member said, ‘Burleys Wood is a calm and supportive place to work. Residents are treated with respect, and staff try their best to meet their individual needs.’

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager did not always promote an inclusive culture at the service. Staff gave mixed feedback regarding the registered manager. Comments from staff were varied. One staff member told us, ‘I have no concerns or issues at all, I enjoy working there. It is a lovely environment to work in and for the residents to live in. All the staff, team leaders and managers are all so friendly always there to help and can any questions I may have.’ Whilst another staff member told us, ‘Visa sponsored staff are consistently treated as inferior to non sponsored staff by the care home managers. They are spoken to disrespectfully, given unfair workloads, and made to feel that their immigration status prevents them from raising concerns. This behaviour is discriminatory, exploitative, and does not reflect the company’s values. Favouritism is very rife; staff (especially those ‘hooked on visa sponsorship’) are bullied by team leaders.’ There were no records to indicate staff had raised these concerns with the management team.

Following the assessment, we discussed the feedback received from staff with the provider. The provider gave examples of actions Shaw Healthcare had taken in response to our feedback. This included mechanisms they had put in place to facilitate further staff feedback (both anonymously and not). They told us, ‘In response to the feedback received, we arranged for the Head of Recruitment and Sponsorship Lead, Employee Voice Manager and the HR representative for the region to attend the service to offer wellbeing clinics, feedback sessions and catch ups.’ The provider told us, ‘[Their] findings were similar to the areas raised.’ They gave assurances they would take action regarding the feedback from staff.

Many of the staff who provided feedback told us they did not feel listened to.

The registered manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about.

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

Processes were in place to allow staff the opportunity to speak up which included a whistleblowing policy that staff were aware of. However, many staff told us they felt did not confident speaking up. Feedback we received from staff included, ‘Although the organisation encourages openness, the local manager and her team routinely dismiss staff concerns. Staff who raise issues about safety, staffing, or resident needs are ignored or discouraged. This prevents problems from being escalated and creates a culture where staff feel unable to speak up.’ Feedback from another staff member included, ‘Staff are now at the point of not wanting to record incidents as their attitude is becoming ‘what’s the point’ staff do raise concerns with team leaders and managers, but everyone feels very unheard.’

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

Prior to the inspection we received anonymous concerns from staff at Burleys Wood. Their concerns related to, ‘unsafe staffing levels,’ ‘staff being overworked,’ ‘unsupported’ and ‘working without access to care plans or hygiene protocols.’ They spoke of, ‘inappropriate management behaviour,’ ‘intimidation,’ ‘bullying’ and ‘racism.’

During our inspection, staff said they enjoyed working at Burleys Wood. They expressed a commitment to the residents and were keen to provide high-quality person-centred care. However, staff provided feedback that some of the practices at the home were ‘discriminatory,’ ‘exploitative’ and ‘did not reflect the company’s values.’ Over a third of the 30 staff who provided feedback raised concerns. Feedback from staff included, ‘I would like to share my concerns about my workplace. The first thing I would like to mention is about the approach of our management towards staff.’

Following the assessment, we discussed the feedback received from staff with the provider. They gave assurances they would take action regarding the feedback from staff.

The staff team did not work well together to support the residents. Concerns were raised by staff regarding the management team, including the team leaders. Staff received training in equality and diversity, however feedback from staff showed this was not consistently put into practice.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They did not always act on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a management structure in the service which provided clear lines of responsibility and accountability. The service was led by a registered manager who demonstrated knowledge of the people living at the service. The registered manager was committed to providing a service that was person-centred and put people firmly at the centre of all they did. Feedback from staff regarding the management team was mixed. Feedback ranged from, ‘[Management’s] interaction with residents is wonderful. They really care for the wellbeing and happiness of the residents who are always happy to see them and have a chat.Their doors are always open to all staff should you wish to discuss anything.They strive to ensure that Burleys is a well-run, happy home not just for the residents but the staff as well.’To, ‘Some team leaders are not friendly or nice,’ and, ‘Me and my colleagues [are under] too much pressure.’ And, ‘We manage. Sometimes it’s too much. Staff are tired. Staff can be scared to ask some team leaders questions (even about residents). [There is] so much to do within a short time. Staff rush things so they’re not told off by team leaders.’

The registered manager had oversight of the service. They undertook a number of regular audits to ensure good quality of care. They understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and report these internally and externally as necessary.

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 registered manager told us they worked in partnership with other organisations. This included a variety of health and social care professionals. All feedback received from visiting healthcare professionals was positive. Visiting healthcare professionals told us, “The staff are a lovely bunch. They take suggestions on board. Staff want to meet people’s needs.”

Staff worked together to enable learning. They participated in training courses to further develop their knowledge. They worked with external professionals including occupational therapists, physiotherapists, dentists, opticians, community matrons, GPs and pharmacists.

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.

The registered manager had oversight of any recorded accidents and incidents. They undertook audits of these to ensure any trends or patterns were identified and addressed. However, the lack of consistent recording of incidents and staff not being enabled to speak up led to a culture which prevented learning and improvement. Staff who provided feedback told us how they were passionate about care, but felt staff were not always listened too.

Visiting healthcare professionals told us, “[Staff] are proactive to support people to achieve rehab goals.” And, “There is consistently good staff, rarely agency staff. Instructions are followed.”

There were systems in place to aid staff with learning. These included regular training sessions for staff, meetings and staff supervisions. There was a service improvement plan which was regularly reviewed and updated.