Bluebell Manor

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

This is the first inspection for this newly registered service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. We found a breach of regulation in relation to the governance and culture of the service. The provider’s governance system was not always effective. When issues had been identified the provider hadn’t always taken timely action to make improvements. The culture of the service was not open, some staff felt unable to speak up and others felt they were not listened to when they did. This included concerns raised about staffing levels which had not been acted on. Healthcare partners said that the management team and staff worked well with them.

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.

Leaders were not always fostering a culture of transparency, engagement and inclusion. Staff described a culture of low morale, particularly around staffing pressures. Staff meetings were taking place, issues were raised by staff but staff felt they did not get an adequate response to these issues. Leaders said they had addressed issues raised however, some communication between staff and leaders appeared to be ineffective. Staff comments included, “The carers here are amazing and I can truly vouch for every single one of them but they are constantly belittled, over worked and unappreciated. The other departments are constantly at our throats rather than helping, there is no team work and everyone is against each other.”

Procedures aimed at supporting a shared direction and positive culture were not always effective. Staff supervisions and meetings were not carried out consistently, or when all staff could attend.

Staff felt the leadership had improved in recent months. Some staff felt they were able to speak to managers while other did not. One staff member commented, “No I do not trust talking to management everything that is said to them which is confidential always seems to find its way out.” The provider felt improvements had been made to the culture of the service since they took over the service. However, we found these improvements were not embedded in the service at the time of inspection.

The provider was supporting the home manager. There had been some instability in management arrangements since the service was registered. The new manager had been in post 3 months at the time of inspection and was in the process of registering with CQC.

Staff told us they did not feel confident to raise concerns with the management team, or that concerns would be acted on. One staff member said, “I know some [staff] feel like they don't have a voice, especially those who have sponsorship and are frightened to stand up, which upsets me.” Another staff member explained that staff feel underappreciated, and their concerns were dismissed in a staff meeting.

The provider had policies in place to enable staff to speak out, however these did not appear to be effectively implemented by the management team. During supervisions, which should be an opportunity for staff to speak freely, staff were told to only speak about positive things when at work.

The provider valued the diversity within their workforce. Staff members did not raise any concerns around diversity and inclusion issues.

The provider had processes in place to ensure staff were treated in an inclusive way. During recent unrest in the local area, the provider had offered staff a safe space to stay rather than commuting home during the unrest.

Leaders said they had been working to improve their auditing systems recently. Staff knew their responsibilities around monitoring, reporting and acting on issues.

The provider was supporting the recently appointed home manager, although there had been some instability in management arrangements since the service was first registered under this provider. The current manager had been in post 3 months, at the time of inspection, and was aware there were still a range of issues that needed to be addressed and actions taken to raise the overall standard of care at the home. The manager was in the process of formally registering with CQC. Governance procedures were in place however, they were not always effective. Issues on medicines, kitchen and care plan audits had been identified but they lacked detail to ensure matters were followed up or issues were not acted on in a timely way. For example, we found one audit, from 3 months prior to the inspection, identified missing records for patch medicines, these were still not in place at the time of the inspection. In some cases actions were in place but deadlines for completion had been missed. Concerns around staffing had been raised with the management team by multiple different means, however, no action had been taken to improve staffing levels or mitigate the risk posed by the staffing disposition. We raised concerns around staffing with the provider, after the inspection they increased staffing on a day shift and put procedures in place to support staff having their breaks.

People appeared happy with the support they received. People and relatives felt staff were competent and they contacted health professionals when this was needed.

Staff understood their duty to collaborate and work in partnership. Staff worked with external agencies and where appropriate shared information and learned with them.

Partners felt the staff and management team worked well with them. When partners raised issues with the management team they had been acted on and improved. At one point NHS staff found the use of agency staff was impacting on the quality of the care provided in the Bluebell unit. The management team had take on board the comments and improvements had been made.

Systems and processes were in place to enable the service to work well with partners. The management team shared information and collaborated with partners to create a good working relationship with good outcomes for people.

Staff did not always feel improvements were made following their feedback. They said culture of the service was not always open to feedback or improvements. Leaders felt that there had been significant improvements to the service in recent months, including improvements to the grounds, new furniture and staff training.

The processes in place did not always support a learning culture. Opportunities for staff to raise issues, were sometimes stymied or no action was taken. When incidents or accidents had occurred then lessons had been learnt and shared with staff. Improvements had been made in conjunction with healthcare partners.