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 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 service good. At this assessment the rating has changed to 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 provider was in breach of legal regulation in relation to the governance systems for the service.

This service scored 61 (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. Staff we spoke with told us they enjoyed their work and liked working for the provider. Staff felt well treated and able to share their ideas and concerns. We observed staff meeting minutes about the aims and vision for different care provision within the service. Staff were encouraged to share their views and ideas which were recorded. For example, leaders wanted to enhance dementia care and support. Leaders had shared their vision, but staff were also encouraged to share feedback on how care could be improved.

Feedback about the management approach was varied. Since our last assessment there had been changes in management. In February 2024, a new home manager had been employed and had recently applied to become registered. Some people and relatives told us they did not know who the manager was and had not had the opportunity to meet with them. The home manager told us they had carried out some ‘meet and greet’ meetings and was still getting to know people. Some day staff told us they had not been formally introduced to the home manager and did not see them around the service. We shared this feedback with the home manager and the provider. The home manager told us they did a daily walk around the home and visited each of the floors to make sure everything was ok. However, this daily check had not been recorded. There were staff meetings held, and minutes recorded discussions. However, some staff told us they had not been able to attend meetings and not seen copies of the minutes to catch up on discussions. Staff told us they felt the management team were approachable and they felt able to ask for help when needed with personal circumstances. Staff had high praise for the deputy manager and their knowledge about the service and people’s needs.

We found 2 examples where staff had not spoken up about concerns. Whilst staff told us they could approach any of the management team with concerns, we found this had not always happened. For example, staff had not reported concerns about being asked to work in a way that was not person-centred. The home manager told us they openly encouraged staff to speak with them and provided staff opportunity to do this. They were not sure why staff had not spoken up about concerns. The provider had an electronic whistleblowing system where staff could leave comments and concerns. Whilst staff had raised some concerns about different topics, they had not raised concerns about the 2 examples we identified. We found information about whistleblowing was not available in staff areas. The home manager took action to address this during our assessment.

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 a range of policies and procedures which supported equality, diversity and inclusion. Management had taken action to support staff who were from overseas and learning English. For example, they had added a programme to their care planning system to help staff with spelling and grammar. All new staff were welcomed to the service with a card and a small gift. Staff received training in a range of areas to support equality, diversity and inclusion. Staff had access to a range of resources to support different preferences, backgrounds and protected characteristics. Staff were able to discuss reasonable adjustments to their work pattern if needed, for example, if they had periods of ill health.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems at the service were not effective in identifying shortfalls in quality and safety of record keeping. We found risk management plans lacked details despite care plans being audited regularly. Accident and incident forms contained incorrect information which had not been identified by the provider governance checks. Actions taken in response to incidents had not always been completed to demonstrate safety checks had been completed. This shortfall had not been identified by the provider governance checks. Improvement needed for legionella safety had been identified and added to an action plan. This work had not been completed within the timescale recorded. Medicines had been audited regularly but we found shortfalls with medicines management which had not been addressed.

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. Whilst professionals thought the staff worked well with them, they did share that communication amongst the staff could be better. One professional said, “I do think communication amongst themselves is an issue. Sometimes something is sorted but we asked to review again, or we get differing opinions amongst the team. They jump into wanting us to do something, but they could communicate effectively between themselves.”

The provider 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 contributed to safe, effective practice and research. The provider had different ways in which learning and innovation was discussed. There was a central office team who were available for management support and to share good practice. Management meetings were held with registered managers from the providers other services. Good practice ideas were shared.