Bourne House Nursing Home

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• 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, following a change of 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 64 (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 always have a clear shared vision, strategy and culture which was consistently embedded across the service.

Whilst there was evidence of a caring culture and positive relationships between leaders, staff, people and relatives, this was not always supported by consistent person-centred practice or effective oversight. Leaders discussed the provider had experienced two recent changes in ownership, and work was on-going to fully integrate and embed their systems and culture.

Many relatives spoke positively about the atmosphere within the home and described a supportive culture. One relative told us, "I think it is genuinely caring, homely and has a family atmosphere about it." Another said, "The staff are wonderful and work as a team, managers and staff all work together." Relatives consistently described the service as calm, welcoming and caring, and told us communication with management was good.

However, we identified examples where the provider's culture was not always reflected in practice. During our assessment we identified aspects of the environment which were not dementia friendly and that the service could do more to promote inclusion. Some staff told us the care could be improved to be more person centred. These findings indicated the provider's vision for person-centred care was not fully embedded across the service and can be improved.

The provider had capable, compassionate and inclusive leaders who were visible within the service and were valued by people, relatives and staff. Leaders encouraged an open and supportive culture and worked alongside staff to support people using the service.

Relatives consistently spoke positively about the registered manager and leadership team. One relative told us, "I would say everything starts at the top, and I have been very impressed with the manager." Another said, "One of the reasons I picked the home was because of [the manager] who is a very nice lady and is very approachable."

Leaders were visible throughout the assessment and demonstrated knowledge of people's needs and service pressures. Clear supervisory arrangements were in place across staff groups, with oversight responsibilities delegated to managers, nurses and heads of department. Staff told us managers were supportive and accessible. One staff member said, "The managers are supportive" and another told us they received good handovers and support when required.

External healthcare professionals also provided positive feedback regarding leadership. A health care professional described the home as well managed and stated the management team were approachable, responsive and collaborative when working with partner organisations.

People did not always feel they could speak up and that their voice would be heard.

Managers told us they encouraged people, relatives and staff to speak up and share concerns. Leaders promoted open communication and there were systems to receive and respond to feedback. The registered manager told us they operated an open-door policy and encouraged staff to raise concerns directly.

Leaders were able to describe how a recent whistleblowing concern had been independently investigated and reviewed. Policies relating to whistleblowing and grievances were available and up to date.

Staff told us they felt able to raise concerns and suggest improvements. Staff said they felt safe raising concerns with managers and regional leaders.

However, whilst systems existed to support speaking up and most staff spoke positively, not all staff felt as safe to share their concerns, which meant that not all staff felt able to speak up.

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 provider promoted equality, diversity and inclusion for staff and people using the service.

Staff described being treated fairly and having access to development opportunities regardless of their role. Policies covering equality, diversity and inclusion were in place and up to date.

Staff told us recruitment processes were fair. One staff member said, "I have the same opportunities as everyone else. We are a team."

The provider did not always have fully effective systems of governance and oversight to ensure risks, performance and quality issues were identified, monitored and addressed in a timely way.

There were governance processes in place across the service, including arrangements for medicines management and the review of incidents, falls and other safety-related events. However, these systems were not always effective in ensuring identified issues were progressed and resolved consistently.

We identified areas where oversight could be strengthened. Environmental concerns identified through infection prevention and control audits, had not always been addressed promptly. Records did not always clearly demonstrate how actions were monitored through to timely completion.

Following organisational changes, the service was operating across two governance systems, which leaders and staff told us created challenges in accessing some records. Actions from meetings were not always tracked to completion, and some staff had outstanding training requirements, limiting assurance that improvements were being effectively overseen.

We also observed staff were not consistently wearing identification badges while on duty. This meant people using the service, visitors and colleagues may not always have been able to easily identify staff members. This indicated oversight of some provider policies and expected standards was not always fully embedded.

These findings showed governance arrangements required further strengthening to provide leaders with effective oversight and assurance that identified actions were completed and improvements sustained.

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 provider worked in partnership with healthcare professionals and local organisations to support people; however, opportunities to extend community involvement and participation were not fully developed.

The home offered activities involving visiting entertainers, therapy dogs, church services and wellbeing activities. Healthcare services such as eye clinics and hairdressing services were also available within the home.

We found activities were delivered within the home environment. This limited opportunities for some people to maintain wider community connections and experiences outside the service. Staff and managers acknowledged that this was an area they could develop.

The provider promoted learning and improvement and had systems to review incidents, complaints and risks. Leaders demonstrated a commitment to improving outcomes for people and learning from experience. Managers described structured approaches for reviewing incidents through daily meetings, clinical risk reviews and serious incident investigations using root cause analysis. Learning from incidents was shared with staff and reviewed by senior leaders and quality assurance teams.

The provider responded positively to feedback during the assessment. For example, action was taken immediately to address issues identified within care records, environmental risks and safety concerns. Leaders also described plans to implement new electronic governance systems to strengthen oversight and quality assurance processes. The home had recently achieved Veteran Friendly Framework status and was developing specialist dementia care expertise by embedding a dementia champion role within the home. These initiatives demonstrated a willingness to innovate and improve the quality of care provided.