Burlington Mews 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 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.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The nominated individual acknowledged that they were working on addressing and improving the culture and direction of the servicewith a new registered manager due to start which hopes to provide stability and a new way of working.

Management and staff at times had a difference of opinions of what good care looked like and how they worked together to achieve it. The nominated induvial told us, “What is most important is that the home is a home. A community which includes going out and having access to everything they want. Making sure people are as independent as they can which improves mental health and encourage everyone to get on well.” Staff spoke of not being supported or having any clear direction. A staff member said, “I feel really unsupported, I am always given little information, and I had little to no induction.” Another staff member said, “The issue is there doesn't seem to be any guidance at the minute.” Policies and procedures had regard to equality and human rights, equity of care experiences, diversity and inclusion and the needs of people.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At the time of our assessment, there was not a registered manager at the home, and the nominated individual was on annual leave. When we arrived it became clear that there was no clarity on who was in charge of the home that day. A deputy manager who was present upon arrival, they were not scheduled on shift but stayed to support us with our assessment. When speaking with the nominated individual regarding this, the nominated individual confirmed that the correct processes were not followed due to the deputy manager starting their employment the week prior. Regardless, this highlighted a gap in knowledge, communication and oversight which left the home vulnerable.

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

Staff told us that they felt uncomfortable speaking up with concerns. Feedback received was that staff would raise concerns to an appropriate leader, but this would either not be taken forward or be told ‘This is how it is’. For example, staff shared that they had continuously voiced that staffing levels need to be increased and they needed more support, but this has not been taken forward. People felt able to raise concerns with staff and leaders, however people we spoke to were unsure who was the person in charge was at the time of inspection.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures supported diversity and inclusion within the service and the provider valued diversity within their workforce. However, staff reported a disconnection to management and leaders, with senior carers feeling like they were ‘stuck between a rock and a hard place’. Staff described positive working relationships and said they supported one another well despite pressures on staffing. Staff were aware of the need to support people’s preferences, including cultural and religious needs.

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.

Quality assurance processes were in place, designed to give an overview of quality of the service. Due to the home not having a registered manager at the time of inspection. The nominated individual had been present within the home until a new manager is employed. The nominated individual told us, “Measuring how a service is working, we look at incidents and accidents first to keep the people that we look after safe. We want staff to let us know what is going on.” However, staff had no clear roles or responsibilities. A staff member said, “Staff could be given a floor or something to focus on, then help others out if their tasks are complete. At the minute, it’s quite chaotic and there's no real structure.”

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 had good relationship with external professionals. Staff said health professionals visited the service regularly and would carry out reviews and provide specialist support when needed.People were supported to access the local community, and they received regular visitors from relatives. A person said, “I accessed local shops independently and visit my wife with the support of my family.”

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.

Staff were encouraged to develop their skills and learning with some staff members being promoted to more senior roles. However, staff feedback showed that support when starting these roles was not always substantial. Our assessment was conducted at a time where the provider was going through a transitional period which has had an impact on being able to deliver creative quality of care for people. The nominated individual acknowledged the difficulties facing the service and stated, “We need to understand that when things go wrong and be open and transparent and learn from it. Learn from our mistakes ensures that we are learning and improving.”