James Burns House

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 inspection we rated this key question good. At this inspection the rating has remained 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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.Staff told us they understood the direction of the service was to enrich the lives of people by providing a place of care, safety and companionship.The management team told us the vision and direction was to provide, “A quality safe service, where people feel they have a voice and they shape the service. We look at what people want and try to provide it. We are 1 family. We are all here to support each other.” We observed staff consistently supporting people in this way. Managers and staff actively sought the views of people and their families through meetings, surveys and reviews. Relatives told us they were included.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. People, their relatives and staff were complimentary about the leadership of the service.We received positive feedback about the management of the service. A person said, “They are very good. They are easy to talk to.” A relative said “Management team are good and are on it.” People and their relatives knew who the manager was and told us they were accessible to them whenever they needed.The manager had the right knowledge, skills, and experience to lead the team.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.Staff knew how to raise concerns and ‘speak up.’ People and their relatives were provided with various ways to give their views on the service. They told us they were happy to speak with staff or the manager to address any concerns. A person said, “I would speak to (name), I feel comfortable to speak up.” The provider had policies and procedures in place to support staff in speaking up and raising concerns. Staff confirmed they knew how to whistle blow.A staff member told us, “We can speak up, the service act on it, and we work here as a team. We are family here. Everyone is approachable.”

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The service was built on inclusivity. There was a diverse staff team who were encouraged to share their values and morals. Everyone was welcomed in the service.Staff told us they felt accepted by their colleagues, and felt teamwork was 1 of their strengths. Another staff member said, “The team work very hard and solidly; I have a lot of respect for them.” A family member told us, “Continuity of staff is fantastic. Many staff have been here a long time, and all bring different things to the home.”

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. People, their relatives and staff were complimentary about the leadership of the service.There was a schedule of audits and checks in place to identify areas for improvement. These included, health and safety, analysis of accidents and incidents and medicines. The manager and provider had made all notifications to CQC as required by law. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. The manager had over-sight of the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. The service shared information and worked with a wide range of professionals and external organisations. People told us they were part of their community. The activities program included regular community involvement, such as, shopping trips, air hockey, walks, darts, cinema visits, BBQs, and other community outings. There was a yearly Christmas lunch at the local pub, people told us they looked forward to this. Local communities were invited into the service regularly. We were told about local schools preforming songs, a national company decorating the home for Christmas and carrying out projects, such as, updating the garden. The service understood the importance of engagement with external stakeholders and professionals. Health and social care professionals were complimentary about working with the service. A professional said, “I have a good professional relationship with the manager, I have been working with the service for several years.”

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research. The service continually sought to engage with people and improve outcomes. This included listening to feedback. The manager had oversight of the service and undertook their own internal audits and checks to ensure safe operation of the service. Additionally, the provider undertook further audits and checks to develop the service and identify areas for improvement. We were told by the provider they planned to introduce an electronic care planning system as this would benefit people, staff and the service.