Blenheim House 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 68 (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 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.

Provider values were shared with staff during their induction and were available on the provider electronic systems which staff regularly accessed. Provider representatives regularly visited the service, and staff were familiar with who they were and what their role was.

The new registered manager walked around the service daily and chaired daily heads of department meetings. This helped to make sure the provider’s standards and expectations were shared with staff consistently.

The registered manager shared examples with us of how they tried to create a culture of support for staff and provide opportunities for learning and development. They said, “I give staff time, I walk the floors and talk with them. We try and value the staff, give them more responsibility if they want this.” Staff had been provided with opportunities to do work-based qualifications.

When leaders had investigated any concerns about poor care, senior staff had been encouraged to be involved in this process so they could learn about why the provider standards of care were important.

The provider 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.

Since our last inspection there had been changes to the management team at the service. There was a new registered manager who had worked at the service previously and was familiar with the provider policies and procedures. Prior to our inspection a new clinical deputy manager had started work. The registered manager was confident this role would better support the nursing staff and have good oversight of clinical governance.

Whilst these new staff were settling into their posts, the quality director was visiting the service more frequently to provide management and staff with more support. Feedback about the management team from staff was positive. Staff felt able to approach the registered manager and were confident any concerns would be listened to.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager told us they actively encouraged staff to come to them with any concerns. They shared examples of how staff had reported incidents of poor care which had been thoroughly investigated. A listening event had been held where staff had been encouraged to discuss what was working well at the service and what was not going well. Action had been taken to make changes in response to staff feedback. The registered manager told us they planned to do more of these events for staff.

We saw examples of duty of candour processes. When things had gone wrong the registered manager had written to people involved to apologise.

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 had policies and procedures for equality, diversity and inclusion. Staff completed training on this topic and there was guidance available on the provider’s electronic support system for staff.

The registered manager told us they created a culture where all staff felt part of the team. If staff had cultural needs, these were respected. For example, if staff wanted to regularly attend church services, this was factored into working hours. Leaders completed wellbeing checks for staff and supported them to return to work after absence.

Work had been completed to raise awareness and support for neurodiversity amongst the staff. The registered manager shared examples of how the service had supported staff to have structure to their working environment. This helped to reduce anxieties and supported staff to have better days at work.

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.

Following the last inspection, the provider sent us an action plan which recorded what changes they would be making to improve governance. Whilst action had been taken to address many shortfalls, further improvement was needed to embed and sustain quality monitoring.

For example, the provider told us care planning would be improved by a ‘resident of the day’ system which was used to review care plans. Whilst this system was helping to review people’s care plans, we still found some conflicting information in risk management plans. The provider told us there would be a daily walkaround check completed by leaders. Whilst this had been completed, this check did not identify hazards in the environment which we have reported on in the key question safe.

The provider had online systems for managers to identify quality monitoring data. This helped to make sure actions were completed in a timely way. However, not all actions had been added to this system. The provider took action during the inspection to address this shortfall.

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 service worked in partnership with a range of healthcare professionals to ensure people’s health needs were met. Some professionals were regular visitors to the service to provide people with a consistency with their health care. For example, community nurses, the local GP, dementia specialists and social workers were regularly visiting people at the service. Feedback from 1 professional was that they could see improvements had been made at the service, however, further improvement was needed. They said changes in management had been positive for the service and concerns were now being listened to. Another professional said they had no concerns with the care being delivered at the service and staff communicated with them well. Staff were responsive to their advice and followed set care plans for people’s health needs.

Leaders were familiar with what services were available to people locally and organised for people to access them in a timely way.

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 taking action to support people, which was not contributing to a safe environment. Research had not been completed to identify better and safer ways of supporting people. Whilst leaders and the provider were responsive to CQC feedback during site visits, the provider’s own learning and development systems should be pro-active in identifying good practice in all areas.

The provider was piloting some different ways of working in some of their services. Once evaluation had taken place and if the different systems were beneficial, they would be shared across all of their services. This included the provider piloting the use of artificial intelligence in care planning.