Burnham

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

The management team told us that they and the service were looking at ways to continually improve, some actions to make improvements had taken place and more were planned. Accident, incidents, complaints or other significant events were recorded. However, there was no evidence to analyse the trends and patterns. Systems and processes to audit and check the service were in place, however these were not always robust. This evidenced that the legal requirement in relation to good governance had not been met. Staff told us they liked working in the service. Staff said the new management team were supportive and approachable. Staff were confident that they could discuss any concerns with the management team and these would be acted on.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team were clear they wanted to improve the service and outcomes for people. The staff gave positive feedback about the culture of the service in recent months but raised concerns that there had been a serious issue with the culture at the service prior to this. The provider had taken action to address this. Staff reported a positive open culture where they now felt empowered to raise any concerns or make suggestions. Comments included, “Everything has changed for the better, residents have a voice now, they have choices, the home is now their home, it is a different place. It is very positive, there is still a lot of work to do. I had raised concerns a number of times before. It was hideous before”; “I am optimistic that there will be improvements” and “Things are running much better now. They say thank you and recognise us for doing a good job.” Staff told us there were meetings they could attend. A staff member said, “There is a team meeting planned for the next few weeks, we had one after the manager left.”

The provider and the management team had kept up to date with local and national developments within health and social care and had attended forums, training and signed up to well known, reputable websites to find advice and guidance such as Skills for Care. Skills for Care supports adult social care employers to deliver what the people they support need and what commissioners and regulators expect. The management team used opportunities to gather feedback from people and staff. There were regular meetings with people and, participation and comments were encouraged. Records showed a meeting took place with people which discussed activities, menu changes and staffing. A person told us, “[Manager] is in charge now. [Manager] is really, really good, she is brilliant. Now I feel confident to discuss things with [listed members of the management team].”

The management team knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with a new manager who was in the process of registering with the Care Quality Commission. They were supported by a registered manager from one of the provider’s other local services, the regional manager and the quality and safeguarding manager. Staff understood their responsibilities to meet regulatory requirements. The management team were present at the service regularly and undertook checks and audits. The management team told us they were well supported by the provider.

The management team led with integrity, openness and honesty to ensure care and support was delivered in line with people’s wishes, expectations to embody the culture and values of the workforce and organisation. People told us the management team had an open-door policy and made time to talk with them. Relatives told us that communication had been poor, however they had all now been contacted and invited to a meeting. A relative said, “I did get an email from the new manager last week inviting me to a family and friends meeting at the home on 18 November 2024.”

Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that there had been one in July 2024. Staff were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “I feel listened to. We have had 1 staff meeting since June.” Another staff member told us, “I would take it to [manager] and would report it higher, they are very approachable.” Staff members discussed that previously they had not been listened to and heard which impacted on people living at the service and staff. This was reported by staff to senior managers and appropriate action was taken to address this.

The provider had systems and processes in place to foster a positive culture where people felt that they could speak up and have their voices heard. Complaints processes were available. A person told us, “I say things I don’t like. I would talk to [manager] if I was not happy, I trust her a lot.”

The management team told us that staff are well supported with staff care packages. These included access to a nationally recognised discount scheme for health and care workers, access to a holiday home, a bonus after 2 years service. Staff were given a day off for Christmas shopping and they were given their birthday off. Staff also had access to private counselling and private healthcare. A staff member said, “We have staff care package, I have a phone number I can access and we have access to the Blue Light Card.”

The provider had processes in place to encourage an inclusive culture. Actions to address areas of concern about the previous culture had been taken. The provider cared about and promoted the wellbeing of their staff and supported and enabled staff to deliver person-centred care.

Staff told us they liked working in the service. Staff said the new management team were supportive and approachable. Staff were confident that they could discuss any concerns with the management team and these would be acted on, they were aware of how to escalate concerns to senior management or outside of the organisation. A member of staff said, “I feel I could whistle blow to the new management and also outside.”

The provider had an audit programme in place. Regular audits were undertaken by the management team. These had not been robust audits and issues found during this assessment had not always been identified. For example, the training audit undertaken on 10 April 2024 stated that all staff had been involved in a fire drill within 12 months, this was incorrect. The health and safety and fire audit completed in October 2024 also stated that fire drills had taken place and that fire tests had been happening weekly. Audits had not highlighted issues with risk management or infection control risks. The quality and safeguarding manager told us the provider was creating a process to review and check the audits completed by managers/individual services. This was being put in place to ensure the provider had oversight of the service and that audits were robust as well as preventing closed cultures within the service. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The management team had not always submitted notifications to CQC in a timely manner, they identified this during the assessment when they found CQC had not been informed of DoLS authorisations. They sent the notifications to CQC in retrospect. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so.

People told us that they liked the new management team and felt listened to. A person said, “Once a month we put in ideas for what we want for lunch. We are making arrangements to have a takeaway.” Some people had been supported to access the community regularly with staff, friends and relatives. A relative told us their loved one had been supported by a family member to attend a big family party. Relatives did not feel that they had been kept fully informed of what had been happening in the service. Comment included, “I wasn’t told about the management change and the first I heard about was last week when [safeguarding and quality manager] rang to ask permission for [CQC] to call”; “We were told [safeguarding and quality manager] would be meeting with us after everything and that has not happened” and “I had a call from [safeguarding and quality manager] a few months ago regarding a safeguarding that had been raised on the home. I then did not hear another thing at all until he rang last week when he called to ask if [CQC] could contact me. I raised this with him and he apologised. We found out from an outside source that [previous registered manager] had gone.”

All staff worked closely with visiting health and social care professionals. Staff explained how they welcomed visitors and visitors. A staff member said, “Families come to visit, we make them feel welcome and offer tea and biscuits.”

A local authority commissioner told us they had visited the service in July 2024 following an incident which was reported by the provider to the local authority. They said that changes had been made and improvements were planned. A health and social care professional told us, “From the visits I have made to the care home staff have all been very helpful and supportive to me and patients.”

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement.

The quality and safeguarding manager told us the provider was looking to introduce peer audits in 2025. This type of audit would mean a manager from another service would come in and check the service. This is in response to ensuring the provider learns lessons from the safeguarding concerns that happened at the service in the summer.

Incident and accidents that had occurred had been acted on, however there was no record of the analysis and actions. We reported about this in the safe key question. The management team shared how they would be developing and improving the documentation going forward. The peer review process planned by the provider would encourage a critical 3rd party view of the service, with a fresh perspective and encourage more of an open culture in the service.