Burrow Down Shortbreaks

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 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 had failed to comply with a condition of their registration and was in breach of legal regulation in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager 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 told us they promoted an open and honest culture. Information was shared with staff through daily handovers, supervision sessions, and regular team meetings. Staff were provided with a positive work environment where ideas and suggestions were encouraged, supporting a culture in which staff felt valued.

Staff achievements were recognised through positive feedback forms, and an ‘Employee of the Month’ scheme was in place, with recipients receiving a voucher and card. These initiatives have helped to reduce, though not fully resolve, issues such as staff burnout, retention challenges, and sickness levels.

A relative said, “The staff are kind, caring and compassionate and the managers are both approachable. I would recommend to others; The only way to make it better is to extend the house for more people to go."

Not all leaders understood the context in which the provider delivered care, treatment, and support. Leaders did not always demonstrate the skills, knowledge, or experience to lead effectively.

The registered manager and provider did not demonstrate sufficient oversight of the service to ensure people received care and support that always promoted their wellbeing and protected them from harm. They did not identify the concerns we found at this assessment.

In addition, we found the provider and registered manager did not fully understand the conditions of their registration. This resulted in care and support being provided at a location that was not registered with the Care Quality Commission, which is a breach of a condition of their registration.

Although policies and procedures were in place, they were not consistently followed. This included key areas such as care planning, risk management, medicines administration, application of the Mental Capacity Act 2005, and staff recruitment. This contributed to a breach of regulations relating to safe care and treatment, the need for consent and good governance.

The registered manager was aware of their responsibilities under the Health and Social Care Act, including the duty of candour, the obligation to be open and honest when an accident or incident occurs that has caused or placed a person at risk of harm.

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

Relatives consistently told us they were able to speak up and raise concerns if something was not right. One relative said, “I have no complaints or concerns and would definitely recommend it to others. I can’t fault the service.” Another said, “I have no complaints or concerns. They [meaning the registered and deputy managers] are both very approachable.

The provider had policies in place to support staff to speak up, raise concerns, and keep people safe. Staff spoke positively about the registered manager and deputy managers. They told us they felt able to raise concerns if needed, both internally and externally to the local authority. Comments included, “[Registered manager name] is very professional and if I go to her with an issue, most of the time it does get resolved,” “Yes, [registered and deputy managers names] manage it well and they are friendly and lovely so no problem going to them,” and “Yes, with [registered and deputy managers names] if there are any issues you don’t need to book an appt you just walk up there or they come and get a coffee in the kitchen and they are always around and I would have no problem approaching them with anything.”

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 registered manager told us they aimed to create an environment where staff felt treated with dignity and respect. They said the service did not tolerate bullying, harassment, or discrimination. The staff team was diverse, with a mix of genders, ethnicities, and backgrounds, and staff were made to feel welcome and accepted. One staff member said, “Staff help each other, and we all work together to make it as seamless as possible. The team work well together.” The registered manager said, “We provide continuous support and monitor progress, it’s important that all staff feel supported.”

Policies stated recruitment decisions would not be based on ethnicity, sexual orientation, age, race, gender, disability, gender reassignment, or any other characteristic that could lead to discrimination. All staff were required to complete equality and diversity training.

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 processes were not effective in keeping people safe, protecting their rights, or ensuring staff had the information necessary to meet individuals’ needs. These systems failed to drive improvement, did not identify the issues highlighted during this assessment, and could not be relied upon to measure quality or manage risk. Concerns included the management of risks relating to people’s assessed needs, upholding people’s rights, the environment, recruitment, and the safe handling of medicines.

The provider’s oversight and governance of the service had been ineffective in identifying and addressing failings in safety, quality, and standards, as detailed in the Safe, Effective, and Well-Led sections of this report. This contributed to a breach of regulation relating to good governance.

Following the inspection, the provider confirmed action had been taken to strengthen oversight and support the day-to-day management of the service. These measures were intended to address the concerns identified and improve the quality and safety of care provided. The provider was engaging positively with the local authority to address all aspects of service delivery and drive improvements across their services.

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 registered manager recognised the importance of working in partnership to improve people’s outcomes. They described how they worked in close partnership with people, their families where appropriate and the local authority to achieve good outcomes for people. The registered manager said,“One thing we identified, we were not getting good survey return rates in relation to people’s experience. So, we improved the survey for people into an easy read format.”Records showed staff worked with healthcare professionals, including GPs, district nurses, and the Learning Disability Intensive Assessment and Treatment Team (IATT), to support people. Staff described how they worked with external professionals. For example, liaising with day centres or taking people to appointments and feeding back to relatives.

Relatives reported communication with the service was good. However, we received mixed feedback about how the service engaged with relatives in terms of seeking feedback. One relative said. I don’t think I have had a questionnaire, but [Registered and Deputy managers’ names] are available and approachable and do return my calls.” Another said, “I haven’t, but my daughter was given a questionnaire to fill in, but I fill it in as my daughter is unable to do it.”

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider had not fully established or embedded a proactive and positive learning culture in which issues related to safety and quality were promptly identified, listened to, and addressed. For example, we found the management team had been slow to act on advice provided in relation to fire safety and regulatory compliance. This failure contributed to a breach of regulatory requirements concerning good governance.

However, concerns and complaints were acknowledged, investigated and acted upon promptly, which helped to drive improvements in the quality of care and support provided.

Throughout the assessment, the registered and deputy managers were open and honest, acknowledged areas requiring improvement and demonstrated a commitment to address concerns and improve staff practice. They took action to address areas of concern and described how they would use the feedback provided to inform the development of a comprehensive service improvement plan to strengthen governance arrangements.