Burntwood Lodge

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 service was in breach of legal regulation in relation to governance at the service.
 

This service scored 46 (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 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.

We found a number of concerns that indicated the provider's values were not consistently embedded in practice. Leaders did not always demonstrate an understanding of the challenges experienced by people using the service or how care should be delivered in line with best practice for people with a learning disability.

The provider did not always have an understanding of people's communication needs or how to engage them meaningfully. There was also evidence of practice that was not open, person-centred or transparent. We found staff had written care notes in advance of providing care. This meant records did not accurately reflect the care people had received and reduced assurance regarding the reliability of documentation. Staff checklists also still included the name of a person who had passed away, with the name simply crossed through rather than documents being updated. This failed to reflect a respectful and person-centred culture that recognised the significance of a person's death.

Whilst there were some positive interactions between staff and people and examples of compassionate care, the provider could not demonstrate a clear, consistently embedded culture that promoted transparency, inclusion, equality, human rights and meaningful engagement.

Some staff and relatives spoke positively about the support they received from management. Comments included, “[Registered manager] is very fair, he is nice. He will also say he has time to sort things out. He is a lovely person. He is very good”, “I do feel supported by the manager, he is very open, I don’t feel he is closed and he is supportive when I need it” and “[Registered manager, he’s very approachable.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders did not always demonstrate a sufficient understanding of the context in which care, treatment and support were being delivered. Whilst there was a registered manager and management structure in place, we found significant gaps in leadership oversight, workforce support and performance management which substantially reduced assurance that leaders consistently promoted a positive and person-centred culture.

Arrangements to support and develop managers were not always effective. Records showed the registered manager and deputy manager had not received any recorded supervision. This meant there were limited opportunities for reflection, challenge, professional development and oversight of their performance and responsibilities.

Whilst some staff told us they felt supported by management and were able to seek advice when required, others reported that management did not always respond appropriately. One told us, “I don’t always feel listened to. I feel like I’m being nuisance.” This indicated staff experiences of leadership and support were not consistent.

However, other staff told us they did feel listened to and supported. One member of staff told us, “I feel listened to, if there is anything that I think needs to happen, I feel very respected with the staff and the owner as well.”

People did not always feel they could speak up and that their voice would be heard.

The provider did not always provide a culture where staff consistently felt listened to, valued and confident that concerns would be acted upon. Feedback received during the assessment was not consistently positive. Some staff told us they did not feel adequately supported following incidents where they had been injured by people using the service. These staff felt management did not always acknowledge the impact incidents had on them or take sufficient action to support their wellbeing.

However, the provider had some arrangements in place to enable staff to raise concerns. Staff demonstrated an understanding of their safeguarding responsibilities and were able to describe how they would report concerns about people's safety and wellbeing. During the inspection, there was no evidence that staff were reluctant to report safeguarding concerns or incidents.

Comments from staff included, “If there is something I don’t agree with, I will speak up. I will say to the staff, encourage them to bring things up in supervisions and meetings.” and “If there anything I am concerned with, I will tell the manager.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider benefited from a diverse workforce, with staff from a range of cultural and ethnic backgrounds working within the service. Staff told us they felt welcomed and valued as members of the team. This helped to promote an inclusive working environment and brought a variety of experiences and perspectives to the support provided to people. A member of staff told us, “They [leaders] are all very nice. Everyone is respected equally.”

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.

The provider's governance, management and oversight arrangements were ineffective and failed to identify, monitor and address a number of significant concerns identified during the assessment. The wide raging nature of the issues found demonstrated that quality assurance systems were not operating effectively and did not enable leaders to maintain oversight of the quality and safety of the service.

We identified concerns across multiple areas of the service, including medicines management, infection prevention and control, assessment processes, risk management, safeguarding, workforce development, communication support, person-centred care and monitoring of health outcomes. These issues had either not been identified by the provider or had not been addressed effectively through governance processes.

Workforce governance was also ineffective. Staff had not received training in RS, RC, RC and leaders had not received specific training relating to learning disability and autism. In addition, the registered manager and deputy manager had not received regular supervision. The provider did not have oversight of the service or effective arrangements for monitoring competence, supporting leaders or addressing poor staff practice when concerns were identified.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Partnership working was not always effective in ensuring people experienced coordinated and seamless care. The provider did not consistently demonstrate that comprehensive assessments of people's needs were shared when people transferred between services. This created a risk that important information relating to people's health, wellbeing, communication and support needs may not always be available to those responsible for providing care.

Recommendations made by professionals were not always implemented in practice. For example, a Speech and Language Therapist had recommended the use of a visual timetable for 1 person, and this was recorded within their care plan. Despite this, a visual timetable had not been developed or introduced as confirmed by the registered manager. This meant the provider could not be assured that professional guidance was being consistently followed to support the person's communication and understanding.

However, referrals to external health and social care professionals were made promptly when people’s needs were identified. Staff worked appropriately with partner agencies to ensure people received timely access to specialist advice, assessment and support. One external professional told us, “We hold annual reviews for our people and Burntwood Lodge always ensure review documents are completed on time and are written clearly.”

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.

The provider did not have effective systems in place to learn from incidents, drive improvement or promote innovation. The inspection identified widespread governance failures which demonstrated that opportunities to identify concerns, learn from events and improve the quality of care were routinely missed. Whilst staff took immediate action when incidents occurred, there was no evidence that incidents were subject to meaningful review, analysis or organisational learning. Records did not demonstrate that trends, patterns or recurring themes were identified and used to improve care delivery, reduce risk or support staff development. As a result, the provider could not demonstrate a culture of continuous learning and improvement.

There was also little evidence the provider used feedback from people, relatives, staff or professionals to inform service development. Resident meetings were not always meaningful, key worker meetings lacked evidence of effective engagement, no satisfaction surveys had been completed, and communication methods were not adapted to meet people's individual needs. As a result, the provider did not ensure that learning was informed by people's experiences.