The Burroughs

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. This key question has been rated 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 service was in breach of the legal regulation in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People using the service and their relatives had mixed experiences. Some people felt that their needs were not always met in a person-centred way and relatives felt some people waited for care. Some people and relatives explained care staff did not always have the skills needed to understand about dementia and managing challenging situations. A relative commented, “Some staff are really good. But others do not seem to understand dementia.” Some people and relatives felt their concerns were not acted on. A relative commented, “It sometimes feels like the service is run for the convenience of staff rather than individual people.”

People told us the team leaders and senior staff were needed to manage different situations. Care staff who spoke with us often referred to the senior staff as those that would deal with incidents, emergencies and difficult situations. Some care staff were not able to explain how they would respond to allegations of abuse, how they would deal with accidents or how to support people’s differing needs. They explained they would defer to senior staff. We found senior staff were knowledgeable and knew how to manage different scenarios. We discussed feedback from people, relatives and our conversations with care staff with the registered manager so they could look at ways to improve the situation.

However, people and relatives liked the staff and found them kind, caring and supportive.

Staff told us they enjoyed working at the service and believed in the company’s values. Comments from staff included, “I love my job and the best part is making a difference for people” and “I would recommend this as a good place to work.” External professionals told us they thought the service provided good quality of care.

The leaders had not always identified where there were breaches of legal regulations. Whilst leaders conducted audits and checks, these had not always been effective at identifying or responding to risk.

The registered manager was an experienced care professional and had undertaken qualifications in care management. The provider was in the process of recruiting a clinical lead who would oversee nursing care at the service. People, relatives and staff told us the registered manager was visible and available when they needed them. Comments from people using the service and relatives included, “The managers are very friendly” and “The manager is lovely.” An external professional explained the registered manager was available when they needed and acted on feedback they shared.

There were systems to enable staff and others to speak up when they felt something was wrong. However, some people felt that action was not taken when they raised concerns. Staff told us they knew what to do if they wanted to speak up. Comments from staff included, “I can approach the manager who is very supportive” and “There is a good atmosphere, and we are able to speak up.”

There were policies and procedures to support workforce equality, diversity and inclusion. Staff told us their individual needs and diversity needs were respected. The registered manager supported staff with flexible working arrangements. Comments from staff included, “I feel respected. The service treats everyone fairly”, “My individual needs are respected. The service promotes equality, diversity, and inclusion and provides a safe and supportive working environment” and “Whenever I need a day off, they are understanding.” Some staff were wellbeing champions, and some were mental health first aid trained. This meant other staff had peers they could speak with if they had any concerns about their wellbeing or needed extra support.

The provider’s systems for monitoring and improving the quality of the service were not always robust or effective. For example, we found equipment and areas of the environment were not always working or clean. The provider’s own audits of these had failed to identify where some improvements were needed. The provider had also failed to always identify when improvements were needed to care records, risk management plans and systems for the safe management of medicines. The provider conducted a range of audits and had plans to take action when they identified concerns.

Following our visit to the service, the provider sent us an action plan outlining how they would make improvements in the areas where we identified these were needed. This response provided us with some assurances. However, failure to identify, monitor and mitigate risks as well as failures to ensure records were up to date and accurate was a breach of legal requirements. Additionally, whilst some people had a good experience of the service, other people’s care needs were not always being met.

The registered manager explained they felt, “Confident that the actions implemented will continue to improve the quality and safety of the service and support positive outcomes.”

The provider worked in partnership with others. They had regular contact and meetings with doctors and nurses who visited or telephoned the service each day. They worked together to provide continuity of care. External professionals explained they worked well with the registered manager and senior staff. Their comments included, “[Managers} are happy to contact me to discuss concerns”, “Staff are always friendly and welcoming” and “I have a good working relationship with the team at The Burroughs.”

The provider had links with local schools, places of worship and other community groups who visited the service.

The registered manager attended forums and networked with other care managers to share ideas, good practice and learning when things went wrong.

There were systems to learn when things went wrong. Following our visit to the service, the registered manager sent us an action plan setting out how and when they would make improvements to the service. These included improving staff training, audits and governance oversight. The registered manager explained they would carry out further engagement with people using the service, relatives and staff to gather their feedback and to make sure they were happy with outcomes.

There was a programme of staff training and staff discussed key themes during meetings to help improve their knowledge and skills.

Some of the staff had extra responsibilities to lead in specific areas. They completed advanced training and helped to educate other staff.