Burwood Grange 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 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 clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of the challenges and the needs of people and their communities.

The registered manager told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. Staff told us there was a positive culture within the home where people and staff had a good rapport, and the atmosphere was calm and caring.

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions. They told us, “We have an open-door policy. Good relationships with residents’ families. It is paramount to maintaining a good culture. We tell families if we get something wrong. It’s a calm home with a good atmosphere. We have not have any challenges in relation to a closed culture.”

The management team were passionate and committed to developing the service for the benefit of people who used it. The regional director told us, “We have an occupancy budget to work to. It has to be the right people who can be happy in this home. We do want the home to fill but we are doing it gradually.”

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.

People and relatives knew who the registered manager was and told us they had a good relationship with them and the rest of the staff. One person said, “The manager is approachable. [They do] come round to say hello” and another commented, “I’ve met the manager and [they] seem very nice.” Relatives agreed and said, “The manager is very visible, and he does listen if there is a problem” and “I really am very very grateful for [Registered manager] and really appreciate [them] and [Deputy manager]. They are very professional and approachable. [Registered manager] is so good with the residents.”

All the staff we spoke with were positive about the registered manager and provider. They told us the service was good and the managers respected and valued them. Their comments included, “I have always been able to speak with [Registered manager] and [their] door is always open”, “It feels like [they] believe in us, and appreciate us. Everyone should have that support” and “The manager shows us respect.”

The registered manager was well qualified and had developed a good knowledge of the client group they supported. They told us, “I have been managing care homes for 15 years now. There are challenges but I enjoy people. It has given me a better understanding of what life is all about.”

They enjoyed working at the service and had a good relationship with staff and people alike. They felt supported by their line manager.

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

People and relatives were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint.

Staff told us they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home.

The provider had some processes in place to support staff to speak up. This included supervision meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

In addition to regular staff meetings, there were daily handover meetings to discuss important information, and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

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 registered manager told us, “We are flexible about staff. If they have a health condition, we support them with their needs. We do move days around to help staff if they need childcare etc.”

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. Staff were supported to develop their skills within the company.

Staff’s cultural and religious needs were supported. People and staff’s sexuality and identification was respected. This included how they wanted to identify and their choice of pronouns.

The provider had clear responsibilities, roles, systems of accountability and good governance. Overall, systems in place for monitoring the quality of the service were effective. However, audits had not always identified shortfalls. For example there was a lack of activities provided on the day of our inspection. The provider explained that the activity coordinator was new. They told us they would address this and ensure improvements would be made in a timely manner.

The environment had not been developed enough to meet the needs of people living with dementia. The registered manager told us this was an area they would prioritise and had started to purchase equipment for this.

People told us they did not always like the choice of food on offer. The registered manager told us they were in the process of sending the chefs to the provider’s Chef Academy. They said, “This supports chefs to understand ways of cooking to a good standard.” They also told us there were regular kitchen meetings where they discussed any concerns and planned improvements.

The concerns raised in relation to the staffing issues were being looked at by the provider to help ensure there were always enough staff to support people and meet their needs.

The registered manager took immediate action in relation to medicines, and shortfalls had been addressed in a timely manner. Furthermore, they strengthened their monitoring systems to prevent this from happening again.

Staff at all levels understood their roles and their level of accountability. Managers and support staff worked well together and understood how their duties impacted and supported the other.

Staff, people, relatives and external professionals had confidence in the leadership of the service. A healthcare professional told us, “I do visit other care homes too, but I can say Burwood Grange is exceptionally amazing.”

There was a continuity plan in place. This was regularly reviewed and updated as required.

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.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals. For example, the GP and the local authority. They told us, “The local authority organises meetings and training which we are able to attend. Like falls awareness. Paramedics are running an initiative educating staff about DNARs and CPR for example. We have good relationships with the district nurses and other professionals like the chiropodist. Chiropodist and physios have done a talk to the residents to explain what they do.”

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The registered manager told us they ensured the staff learned from healthcare professionals involved in people’s care to help understand people’s needs better. Our conversations with various support staff showed they understood people’s needs and were keen to learn from professional input.

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. They actively contributed to safe, effective practice and research.

People and relatives told us they were consulted individually during a review or regular conversation, to find out if they had any concerns or requests. We saw people’s opinions and requests were taken seriously.

Staff told us the registered manager was always aiming to make improvements to the service to benefit people, and they enjoyed being part of this.

The registered manager was committed to developing the service to benefit people and the staff team. They told us, “We contacted a wildlife organisation, we would like to organise a bee keeping set up with other conversationists looking after it, but we would have access to. This used to be a garden centre and there used to be a farmer’s market. I am trying to find out if we can have this happening here. The gardening service we have currently are also delivering talks to the residents about plants, trees etc.”