Badgers Holt Residential 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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

This meant the service 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 good 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 service 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.

There was a positive and person-centred culture in the service, and staff worked to the same goal. Staff knew people well and spoke knowledgeably about the people they supported.Staff told us they felt part of a team and felt the manager was approachable. Staff received regular supervisions.

The manager told us, “The values of this home are that every resident has the best of everything and everything they need, they get. The resident becomes part of the family. That’s the ethos, we are a family, and we are all working together.”

The service 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.

People and relatives were complimentary about the culture in the service. A relative told us, “Management are kind and thoughtful and always available if you need them by phone or in person.”

Staff told us they felt happy in their roles and supported by the manager. A staff member told us, “I do believe that the manager models inclusive behaviour within our home.”

The manager was knowledgeable about issues and priorities for the quality of services and could access appropriate support.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were aware of their right to speak up and said they were confident the manager and provider would respond positively if they did so.A staff member said, “I feel confident reporting concerns if I have any.”

The provider had safeguarding and whistleblowing policies in place. The manager was aware of the importance of supporting staff to speak up. The manager said, “I am 110% comfortable that staff will speak up when the need to. There is a mantra that if something doesn’t feel right to speak up.”

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they felt valued at work and were confident the manager and provider promoted inclusion and equity.A staff member said, “The provider and the manager give staff excellent support for our well-being. The office door is always open for a chat.”

The service was an inclusive workplace where staff were treated and supported as individuals. One staff member told us about reasonable adjustments made to enable her to work safely.

The service 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.

Governance systems in place were not always robust. The provider did not make all notifications to CQC as required by law. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them.

The provider did not have an effective overview of MCA assessments and best interest decisions. These were not always carried out in line with best practice and some people did not have the necessary paperwork in place.

In response to our feedback the manager submitted notifications retrospectively and introduced a new process to ensure notifications will be submitted and all incidents regularly audited. The manager started to review documentation relating to people’s capacity. The improvements made needed to be embedded into practice and sustained.

The provider had audits in place to monitor the quality and safety of the service. These included health and safety audits. The manager was new to the role and started to develop an overview system for the key areas of the service before our inspection.

Staff spoke positively about the manager. A staff member said,“I know the acting manager and I feel he is approachable. I feel he is a very easy manager to talk to, and I know if I have any issues at all I can speak to him.”

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

People and relatives told us they felt involved in decision making. A relative said, “Emails, texts and calls are always responded to quickly.Also face to face meetings are welcomed if required.”

Staff told us they regularly communicated with health and social care professionals as required to meet people’s needs.

We received positive feedback from health and social care professionals. A professional told us, “The referrals are usually appropriate and well documented with all the necessary information so that we can triage appropriately. When I phone to book the appointments, the receptionist is polite and clear and all staff present as caring, helpful and professional. If a resident needs more urgent attention and the appointment has not yet been booked, the staff chase the appointment in a respectful and diligent manner.”

The provider had a good working relationship with health and social care partners such as district nurses and GPs.The service worked with community groups to maintain people’s local connections. The serviced welcomed visits from local schools.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff told us they were supported to learn and improve in their role.

The provider had systems for sharing lessons learnt with staff. The provider introduced a new service improvement plan, and the management team were committed to ongoing improvement.