Burnham House

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

Quality assurance systems were in place to ensure people received safe and personalised support. Quality monitoring systems were in place to ensure peoples feedback were sought to make improvements to the service. Systems were in place for staff to raise concerns. The care home worked in partnership with external to ensure people were in the best of health. Learning took place following audits and feedback to ensure there is a culture of continuous improvement. People and staff were positive about the management of the home.

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 services Business Plan and Visions and Aims, included consistently providing best quality of life for people, a great place to work for staff and growing the organisation. We found that people were supported well and staff were positive about working at the home. Service objectives were monitored through audits. A equal and diversity policy was in place. People were protected from discrimination within the service.

The registered manager and staff were all aligned towards the vision of the home, which placed people at the heart of the vision. Staff understood that racism, homophobia, transphobia or ageism were forms of abuse. They told us people should not be discriminated against because of their race, gender, age and sexual orientation and all people were treated equally. The registered manager promoted a positive culture within the home. The registered manager told us the culture within the home was open, person centred and empowering, which was done through delivering a quality service and empowering people and staff to make decisions and requesting feedback. There registered manager had a open door culture and therefore support was always available for both staff and people when needed. Staff told us the culture within the home was positive.

A registered manager was in place at the home, who knew the home, people and staff well. Staff were positive about the management of the home and people and relatives told us people enjoyed living at the home. The registered manager had received leadership training as part of their role and told us they were supported. Pre-employment checks had been made prior to employing the registered manager.

Staff were positive about the registered manager. A staff member told us, "The manager is very supportive, understanding and approachable."

Systems were in place for staff to raise concerns internally and externally. A staff member told us, "Yes, very good management system in place that we can talk to anybody if we have any concerns as well as in my supervision."

A whistleblowing policy was in place that included how to raise concerns both internally and externally, which allowed staff freedom to speak up. Staff feedback was also sought as part of supervisions and staff meeting.

A equality and diversity policy was in place and staff had been trained in this area. Systems were in place for flexible working arrangements as shift plans showed staff were able to work flexibly. A flexible working policy was in place. Assistive technology was in place to support staff to look after people such as for people at risk of seizures, a monitoring device was in place in their rooms that alerted staff if a person was to have a seizure. Systems were in place to record incidents towards staff and action taken to ensure staff were safe.

Staff told us they were valued by the management team, there was a open and fair culture within the home and they enjoyed coming to work. A staff member told us, "I look forward to coming to work as I know I am supported to do my job."

The registered manager told us there was robust good governance systems at the home. The registered manager commented, "Daily, weekly, monthly, quarterly checks are carried out at the home and the information is analysed. Area Director then comes in monthly to carry out his audit. Actions are put on the monthly audit plan and actions are worked through and completed.

A Business Continuity Plan was in place and includes information on plan for emergency procedures such as fire, gas leaks, utility failure, evacuation to alternative location. A Quality Assurance Framework was in place that included governance arrangements. Quality Assurance audits were completed by the registered manager monthly, which included focusing on CQC domains such as on staffing, support, training, care plans and risk assessments. Audits included findings and actions to potentially improve standard. Daily walkabout were also completed by the registered manager to ensure standards were being met at the home on a daily basis. Audits were also completed by the area director and a peer review audit was completed by another manager independent to the home to ensure standards were being met and if improvements were required. A Service Development Plan was in place, which included oversight on reviews such as on care plans reviews, audits and DoLs. The plan identified areas of improvement and actions to take to make these improvements to ensure there was a culture of improvement. A Information Governance Policy was in place on how to handle information confidentially, which includes roles and responsibilities, guidance and legislation, data protection and reporting data breach/incidents. Staff understood that personal information should not be shared with others and that maintaining people’s privacy when giving personal care was vital in protecting their dignity.

The registered manager and staff told us they worked in partnership with health and social professionals to ensure peoples needs were consistently met and they received high quality care.

People and relatives were positive about the home and the care they received. This involved working in partnership with external services to ensure people receive high quality care. A relative told us, "I think they [staff] are very caring, they are lovely people, there are always big smiles and I am made to feel very welcome."

Records showed the home working in partnership with social and health professionals to ensure people received safe and effective support. We saw evidence that care reviews taking place with social professionals on peoples care needs.

Feedback from partners were positive about the home and there were no concerns.

The registered manager told us there was a culture of continuous improvement at the home and part of this was through learning and best practices. The registered manager also told us feedback was continuously sought from people, relatives and staff to learn about any potential shortfalls. Any actions arising from feedbacks are put onto a action plan and used to make improvements.

Systems were in place for learning and improvement. A number of improvements had been made since our last inspection. Records showed learning had taken place following our last inspection to ensure improvements had been made. Robust audit arrangements were in place to ensure improvements and learning are sustained. This also meant there was a cycle of continuous improvement. Systems also included identifying regulatory themes and trends such as on areas of MCA/DoLs, record management and staff knowledge. When themes were identified learning takes place such as further training, reviewing policies and strengthening systems.