Burrow Down Community Support

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not ensure the delivery of high-quality care.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, staffing and good governance.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a lack of understanding across the service regarding how to meet regulatory requirements and deliver high-quality supported living for people with a learning disability or autistic people. This was evident throughout the inspection and reflected in the poor culture created by the provider, where some people were not truly valued or empowered.

People were not afforded the right to choose where they lived, who supported them, or with whom they lived. For example, the registered manager told us if someone stopped receiving care and support from Burrow Down Community Support, they would contact the landlord to terminate the person’s tenancy, undermining their right to independent living. Following the inspection, the provider told us, “It is not within the role or authority of the Registered Manager for the support service to take this action.”

People were not consistently treated with dignity and respect. The language used in some care records was disrespectful, and individuals were subjected to punitive practices. Concerns about people’s safety were not always escalated promptly, as detailed in the Safe and Effective sections of this report.

There was a lack of insight and understanding from the registered manager regarding the experience of receiving support from Burrow Down Community Support and the impact this was having on people’s lives. We discussed these findings with the new Operations Director and the Nominated Individual, who acknowledged the service had lost its way following the departure of the local management team. They described the actions being taken to address these concerns and confirmed they were working with staff and the local authority to improve the culture in parts of the service. This contributed to a breach of legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, the need for consent and good governance.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not demonstrate they had the skills, knowledge, or experience to lead effectively.

The registered manager and provider did not demonstrate sufficient oversight of the service to ensure people received care and support that promoted their wellbeing and protected them from harm. They did not identify the concerns we found at this assessment.

The registered manager was not fully aware of their responsibilities under the Health and Social Care Act, including the duty of candour—the obligation to be open and honest when an accident or incident occurs that has caused or placed a person at risk of harm. As a result, they were unable to demonstrate compliance with this regulation, identified within the Safe, Effective, and Well-Led sections of this report.

There was a lack of understanding regarding how to meet regulatory requirements and deliver high-quality supported living for people with a learning disability or autistic people. This had led to a poor culture where people were not always consistently treated with dignity and respect.

Although policies and procedures were in place, they were not consistently followed. This included key areas such as care planning, risk management, medicines administration, application of the Mental Capacity Act 2005, and staff recruitment.

Poor decision-making and judgments placed people at potential risk of harm. For example, in relation to staff recruitment, risk management, and safeguarding individuals from abuse. This contributed to a breach of regulations relating to person-centred care and good governance.

Following the assessment, the Nominated Individual and Operations Director described the action they had taken to strengthen the leadership team. This included the appointment of new staff and enhanced training. These steps were aimed at improving oversight, supporting day-to-day management, and addressing the concerns identified during the inspection.

The provider had policies in place to support staff in raising concerns, such as complaint procedures, whistleblowing policies, staff surveys, supervision, and team meetings, the culture within the service had not always supported openness.

The registered manager told us they aimed to foster a culture of honesty and learning when things went wrong. Staff spoke positively about recent changes, particularly the appointment of the new Operations Director. Comments included: “[Operations Director’s name] has an open-door policy. If I’m struggling, I know I can go to her. The confidence she’s giving me was long overdue.” “Since [Operations Director’s name] started, I feel supported and able to speak up when something isn’t right.” “[Operations Director’s name] is brilliant—she’s picked up on what we need and has been very supportive. It’s the best thing that could have happened to Burrowdown.”

However, while staff were positive about the recent change in leadership, they told us the previous culture had been poor. Comments included: “[Person’s name] was not very supportive.” “There was a bad culture in the office, and I think that’s why things got worse.” “I didn’t feel welcomed when I came into the office.” “You’d raise concerns, but nothing would happen.” “We weren’t encouraged to speak up, and if you did, you were made to feel like it was your fault.” This information contributed to a breach of regulation in relation to good governance.

We discussed these findings with the Nominated Individual, who acknowledged that a “culture of fear” had existed within the service. They described the steps being taken to address this, including the appointment of the new Operations Director, and recognised that cultural change would take time. They had begun to implement improvements through training, supervision, and by encouraging staff to share their experiences.

The provider valued diversity in their workforce.

While the provider demonstrated a commitment to valuing diversity within its workforce, there was a lack of insight and understanding of what it was like to work within the service. Over the past 12 months, the provider had failed to maintain effective oversight, resulting in a missed opportunity to identify and address the poor culture that had developed. This lack of leadership and support contributed to staff feeling marginalised and unsupported in their roles. The lack of oversight and poor staff support had a direct impact on the quality of care and support provided to people using the service. This contributed to a breach of regulation relating to person-centred care and good governance.

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.

Governance processes were not effective in keeping people safe, protecting their rights, or ensuring staff had the necessary skills to meet individuals’ needs. These systems failed to drive improvement, did not identify the issues highlighted during this assessment, and could not be relied upon to measure quality or manage risk. Concerns included failures in person-centred care, dignity and respect, safeguarding, staffing, consent, risk management, and the safe handling of medicines.

The provider’s oversight and governance of the service had been ineffective in identifying and addressing failings in safety, quality, and standards, as detailed in the Safe, Effective, and Well-Led sections of this report. This contributed to a breach of regulation relating to good governance.

The registered manager did not fully understand their responsibilities in relation to the duty of candour. Duty of candour requires providers be open and transparent with people who use services and other people acting lawfully on their behalf in relation to care and treatment. In addition, we found systems had not been effectively operated to identify and report significant events. This had led to the provider not notifying the Care Quality Commission of 8 significant events in line with their legal responsibilities.

This was a breach of regulation in relation to notifying CQC of significant events in line with their legal responsibilities.

Following the inspection, the provider confirmed action had been taken to strengthen oversight and support the day-to-day management of the service. These measures were intended to address the concerns identified and improve the quality and safety of care provided. We also noted the provider was engaging positively with the local authority to address all aspects of service delivery and drive improvements across the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, they did not always share information and learning with partners.

The registered manager recognised the importance of working in partnership to improve people’s outcomes. They described how they worked in close partnership with people, their families where appropriate and the local authority to achieve good outcomes for people. Records showed staff worked with healthcare professionals, including GPs, district nurses, and the speech and language therapy (SALT) team, to support individuals experiencing eating and drinking difficulties. The local authority also provided support to people with a learning disability or autistic people receiving support from the service. However, we found the provider had been slow to identify and escalate concerns.

Relatives reported they had not been formally asked for their views or invited to provide feedback, and many felt communication with the service was poor. One relative stated, “Until the last two weeks, communication has been none.” Another said, “We are kept in the dark. No communication.” This contributed to a breach of regulations relating to person-centred care and good governance.

Following the assessment, the provider sent us feedback they had received from a relative, which stated “[Relative’s name] commented on improvements to communication from management and expressed that her daughter appears happier as a result of improvements made recently.”

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.

Learning did not take place from accidents and incidents. For example, accident and incident analysis did not take place or identify if appropriate action had been taken.

Feedback was sought from people, relatives, staff and other health and social care professionals. However, there was no action taken as a result of these surveys.

Concerns and complaints were not always acknowledged or acted upon in a timely manner to drive improvements in the quality of care and support provided. For instance, 2 relatives reported after raising formal concerns with the service, they received neither an acknowledgement nor a response.

The provider had not established a proactive and positive learning culture in which issues related to safety and quality were promptly identified, listened to, and addressed. This failure contributed to a breach of regulatory requirements concerning good governance.

Throughout the assessment, the Operations Director and registered manager were open and honest, acknowledged areas requiring improvement and demonstrated a commitment to address concerns and improve staff practice. They described how they would use the feedback provided to inform the development of a comprehensive service improvement plan, improve the culture, and strengthen governance arrangements.

The Operations Director outlined plans to promote continuous learning through regular staff meetings focused on work practices, training, and development needs. They told us how enhanced training for the deputy managers, along with improved management oversight, would have a positive impact on both service delivery and governance.