Bourley Grange

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 good. At this assessment 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 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.

The registered manager had ensured there was an open, transparent and positive culture at the service. Staff felt listened to and supported. Staff told us, “My managers are approachable, and they deal with any concerns effectively”, “They [management team] take our ideas into consideration. Sometimes [they] have different views, sometimes [they] agree with us. But its well-balanced”. We observed there to be a positive and caring culture amongst staff at the service. Staff knew people they supported well and were regularly observed to having friendly and person-centred conversations with people. People and relatives told us they felt listened to, “I have spoken to them when they have a moment in the office. If I have complained about anything they ask if there has been any improvement. When they come to my room they don’t just come in and out, they stop for a chat”.

The registered manager and staff team worked diligently to create a positive culture within the service, ensuring it best supported the people living there. The management team maintained a visible and approachable presence, actively seeking and valuing feedback from people using the service, staff, relatives, and professionals.

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.

The management team were welcoming and demonstrated an open and transparent approach. Evidence of team meetings was reviewed and identified that staff had the opportunity to raise concerns. Staff told us they felt listened to by the management team, “We feel supported [by registered manager]. If we need something [registered manager] is there. If [registered manager] can help, they will, and everyone is happy with [registered manager]” and “The management is very very good, and they are good to their staff. They are easy to approach or help with problems to deal with.”

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

The provider followed their complaints and whistle blowing policy and documented all action taken to continue to learn and improve the service. People told us when they raised a concern, staff listened to them. People told us the registered manager was approachable and regularly visible throughout the day and listened to any concerns they may have.

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.

Staff were provided with opportunities to further their development, skills and knowledge and the registered manager proactively encouraged this. Staff wellbeing was prioritised through regular support, open dialogue, and recognition of individual contributions, creating a culture where staff felt valued and empowered. This positive workplace atmosphere contributed to improved morale, and ultimately better outcomes for people using the service. Staff told us they felt supported by the management team, “Our [registered] manager is encouraging and will push us to develop and do more training” and “[Registered manager] is super nice. We feel support with [registered manager] if we need something [registered manager] is there. If [registered manager] canhelp[registered manager]will,and everyone is happy with [registered manager].

The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The registered manager had quality assurance systems in place to review documentation including falls prevention, pressure injury management, nutritional support, staff competency, infection control, care plans and medicines management. An analysis of audits was completed monthly to identify themes and trends to continue to improve the service. Regular team meetings took place and were recorded and reviewed to identify actions. Staff were able to express any concerns, and feedback was provided to staff around any changes to care or any information to share from the resident’s meetings. The management team worked to establish and maintain an open and transparent communication with people’s families

The registered manager maintained close oversight of this process by regularly reviewing the services quarterly action plan and addressing any delays promptly.

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 worked with a number of health and social professionals, this included the local commissioners and health professionals such as, the local GP surgeries, care home support team and the local authority. By working collaboratively, it supported people to achieve positive outcomes in relation to their care and overall wellbeing.

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.

When previous concerns arose regarding an increase in falls and pressure injuries within the service, the management team and provider acted promptly and proactively to address the issue. They identified the trend of an increase in falls and pressure ulcers through their own monitoring and took decisive steps to reduce risks and improve safety. For example, all staff received additional training focused on falls prevention and pressure injury management, including practical strategies to mitigate these risks in daily care.

In addition to enhanced training, the management team introduced a daily review process. This involved checking for any new occurrences of falls or pressure injuries and analysing patterns or emerging themes. By doing so, they were able to identify potential causes early and implement targeted interventions. The services dining team supported the care team to improve fluid intake to people through preparing jelly drops to support people's fluid intake, and increase people's nutrition and hydration in order to support reducing the risk of falls. This continuous learning approach ensured that the service remained responsive and committed to improving outcomes for residents, reinforcing a culture of safety and quality care.

The service had also invested in new innovative technology to support people who have seizures. The device enables staff to detect seizures in real time and intervene promptly, reducing the risk of harm and supporting people's wellbeing.