Beech Haven

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 requires improvement. At this assessment the rating has remained requires improvement

The service was in breach of legal regulation in relation to good governance. Quality assurance systems were in place, but not always effective as they did not always identify where improvements were needed so these could be addressed. This included managing medicines safely and fire processes and procedures.

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 service 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 and staff actively sought the views of people and their families through meetings and surveys. A relative told us, “There are meetings, we had one last Friday. They are quarterly, social affairs and food is provided. The home is very keen to have family involvement. Minutes are taken at the meetings details are produced in the newsletter. I think they are very keen to improve the home and they welcome our input.”

The staff spoke positively about their experience working at the service. They told us they would recommend it as a place to work and a place for a loved one to be cared for.

We observed staff being warm and friendly to people and they seemed to work well as a team.

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. Staff were positive about the support provided by the management team, they felt part of the team and referred to the team of staff including the managers as their family. When we asked staff whether they felt supported in their role, feedback included, “Yes, I’m happy, if I don’t know what to do [the manager] will advise me. I would always go to the manager if I had a problem.” Another staff member, who had worked at the service for a long time, said this reflected how good the workplace was, they told us, The environment is sociable, residents and families, and they get to know us.”

The provider fostered a positive and open culture where people felt their voices were heard. Staff told us they felt confident speaking up and described managers as approachable and receptive to feedback. 1 staff member said, “Every three months we have a meeting where we can discuss areas for improvement. Recently, we raised an issue about the laundry room because the dryer wasn’t positioned correctly. They listened, and now it’s where it should be.”

The registered manager told us “We have an open-door policy and always encourage staff to come to us at any time.”

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 provider had policies and procedures supporting diversity and inclusion within the service in place and promoted diversity and inclusion in the workforce.

The manager told us, “We have a module on Equality and Diversity as part of our induction. We promote respect and dignity for everyone—staff, visitors, and the people living in the home. This also applies to anyone coming into the home. Our induction covers all aspects, and we ensure there is an appreciation for different cultures. We also have our own transport policy and procedure in place.”

Staff spoke positively about working for the service. Some had been employed there for over 10 years, reflecting a level of stability and commitment within the team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s systems for monitoring and improving the quality of the service or mitigating risk had not always been effectively operated. During our assessment we identified risks within the environment, not all staff had completed medicines administration training and some training was out of date. Some care plans we reviewed had not been updated to reflect people’s current needs.

Audits were not always robust and did not always identify areas of improvement and did not identify the concerns we found on our assessment. The audits we received as part of this assessment have not assured us that the provider had effective oversight of the concerns we found on the day of our assessment.

Failure to effectively implement robust systems and processes to monitor and improve quality or monitor and mitigate risks is a breach of good governance.

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 closely with various external agencies including, GPs and the Local Authority. Individuals received regular visits from community groups, such as local churches, and the management team were very welcoming of people’s families. The provider held monthly events where relatives were invited to join activities with their relative. For example, there was a Christmas dinner held at the service for people and their relatives in December, St Patrick day celebrations and an Easter Egg hunt which people and their relatives were invited too.

The provider had systems in place that focused on continuous learning, innovation and improvement. However, these systems were not always effective. Since our last inspection some improvements had been made in relation medication management, however further improvements are required to ensure these are sustained and safe care is provided at all times. For example, some audits lacked detail and were not conducted regularly, such as the home safety audits, care plans, fire safety and medicine audits. Therefore failed to identify key risks and drive improvement.