Blackberry Hill

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 provider 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 management team promoted a culture that staff described as positive, supportive and family‑like. Staff told us they felt listened to and able to raise concerns, with one member of staff explaining, “I definitely would be able to speak with the manager if I had concerns”. This reflected the sense of openness and approachability within the home. People were observed being treated respectfully, and inspectors saw evidence of staff ensuring people had choices, such as when one person was supported to choose which staff member they preferred to work with, demonstrating a culture that respected individuality and autonomy. Relatives also described compassionate care, with one stating that the atmosphere “resonates from the top down, all staff are empathetic.”

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.Leaders demonstrated commitment to the wellbeing of both people and staff and were generally regarded as approachable and responsive. Staff described the registered manager and senior team as supportive and available, telling us, “managers are approachable” and that they could speak to them at any time. The management team were open, honest and responsive throughout assessment, acting on any queries raised.

Relatives frequently commented on the dedication of leaders, and most felt that managers acted promptly when concerns were raised and maintained regular communication. Relatives told us, “We feel very happy very reassured [relative’s] best interest at heart in all they do, very caring place” and “[Manager] works really hard, they all do, buck stops at the top.”

Whilst leadership promoted and encouraged open communication and inclusivity, further improvements in oversight were required to strengthen governance at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us, “Managers are approachable” and felt able to speak openly about any issues they had. Staff demonstrated good awareness of internal and external escalation routes, including the Local Authority, police and the CQC. Staff understood how to whistle blow if required. One member of staff told us they would “Initially inform the senior, the manager or the operations manager. I can also go to the CQC.”

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 they felt treated fairly and included within the team. One staff member stated simply, “Staff are treated fairly”. Staff felt able to provide feedback and contribute ideas to promote change within the service. This supported an inclusive culture where staff felt valued and listened to.

Relatives felt staff provided equitable support to people and did not describe concerns about discriminatory practice, with one telling us, “No absolutely not. Staff treat people equally.” Staff were supported through access to training and development, and newer staff reported feeling welcomed and integrated into the team. Although some relatives noted variability in staff confidence or skill, there was no indication that this reflected inequity in the way staff were supported or valued.

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. The governance systems in place were not robust to ensure effective oversight of the service. Provider audits completed had not identified several shortfalls that we identified during the inspection. This included gaps in care plans and risk assessments, mental capacity assessments, best interest decisions and environmental safety concerns. This meant that the provider was not consistently assured that risks to people were being appropriately assessed, recorded and monitored.

Whilst actions were taken once these were raised, these issues had not been identified through routine checks. Governance systems did not provide reliable assurance, and leaders relied on reactive responses rather than proactive identification of risk.

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 in partnership with a range of professionals to support people’s needs. Relatives consistently described good communication and timely contact with GPs, epilepsy specialists and other clinicians, explaining that staff sought medical support promptly if people were unwell.

Management sought advice and support appropriately to help reduce risks and improve outcomes for people. For example, when a person was at risk of falls, the service made a referral to relevant professionals to address the risk.

Feedback from professionals was positive and demonstrated effective joint working. One professional told us, “[Manager] and her team clearly showed great dedication and commitment to the needs of the person I was allocated to. I was welcomed to the home, accommodated very well. I was able to see the staff on duty and witness their professional approach in supporting the residents I saw during my visit. [Manager] provided me with up to date documents relating to my person's support - clearly highlighting the proactive work her team were doing. Communication with [manager] was clear and punctual and aided my process greatly. Due to the good practice of [manager] and her team the review and consequential actions needed for my person's support were swift and effective.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.There were systems for reporting incidents, safeguarding concerns and accidents, and staff described debriefs and daily handovers where learning was shared. However, learning was not consistently embedded into updating documentation.

The service had undertaken audits. However, these did not identify some of the issues found during our inspection. We found gaps in environmental safety, care plans and risk assessments. Some improvements were made during inspection, such as actions to improve environmental safety and strengthen risk management, but these were reactive rather than preventative. While staff described innovation in activities and engagement, and managers acted on feedback when raised, the approach to continuous improvement lacked structure and consistency. As a result, it was not always clear how the service consistently identified concerns, learned from them, or used this learning to drive continuous improvement. The management team acknowledged the shortfalls and began to take actions to address the concerns.