Burley Hall 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 service under this provider. This key question has been rated Good.This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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. Meetings with staff and people were used to discuss the home’s vision and to share information. This supported people and staff to be involved in how the service was run.

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. Comments included, “The deputy manager is really good they will come and help us on the floor if we are short staffed or help us with anything else we need. They are brilliant. always happy to help us” and “Supervisions are good. We get to speak to each other, and they support us” and “Managers are available on the on-call for help over the weekends which is good.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There were posters up in the home about this and a whistle-blowing policy was in place. The management told us they had an open-door policy. Staff told us, “The manager is approachable and will listen if you have a concern” and “I would meet the manager if I had any concerns or if I saw bad practice.”

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 manager told us the recruitment process was fair, and they employed a diverse work force. The manager was in the process of enrolling staff on more in-depth training on equality, diversity and inclusion and having an equality, diversity and inclusion champion within the home. The home had appropriate polices in place.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We found that effective systems were mainly in place to assess, monitor and mitigate risks to service users and keep them safe. However, we did identify some people’s needs were not robustly monitored. This put people at risk of being harmed and their health and wellbeing deteriorating. For example, some people’s repositioning charts for their skin integrity had longer gaps then their care plan stated and some people who had recent weight loss had some gaps in their meal charts. These concerns had not been identified before our assessment. Further improvements were needed to ensure there was a more robust auditing system in place to identify and acting on concerns.

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. There was a recent safeguarding referral and the home had worked with the local authority and provided an action plan in relation to the concern and lessons learnt.

The provider 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. We found management were investigating and responding to accidents, incidents and complaints. We saw evidence of root cause analysis been completed and lessons learnt documented. A recent concern had been shared with the manager in relation to palliative care. Lessons learnt and actions required were documented and further training for staff was in the process of been arranged.