Beech Hill Grange

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• 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.

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 was previously in breach of the legal regulation in relation to good governance. Insufficient improvements were found at this inspection, and the provider remained in breach of this regulation.
 

This service scored 43 (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, openness and honesty.

At the last inspection we raised concerns about leadership and governance of the service. A new registered manager was in post, and the provider had told us they would ensure that a clear action plan would be implemented to drive improvements which met people’s needs and sustain a good standard of care.

However, the provider’s governance and quality assurance systems and processes had not resulted in sufficient improvements in the quality and safety of people’s care.

We found staff supported people with kindness and understanding. Many staff knew the people they cared for well, and this helped them provide day‑to‑day support. However, this was based mainly on individual staff’s knowledge rather than a clear, shared approach across the whole service.

The provider and registered manager did not have a strong or inclusive strategy that involved all staff in shaping the service. Staff were not routinely included in reviewing people’s care or taking part in improvement work. This meant the service did not have a fully shared vision or consistent culture.

Because of this, the quality of care depended too much on individual staff members rather than a team‑wide understanding of what good, person‑centred care should look like. Therefore, opportunities to learn together, improve practice, and build a stronger culture were missed.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support to the people they provided a service to. Leaders did not always demonstrate the skills, knowledge, experience to lead effectively.

Although the provider had given assurances about actions they planned to take to ensure improvements in people’s care, we found these improvements had not been fully embedded into practice since our last inspection and concerns and breaches of regulations persisted. For example, there was no clear evidence of how people’s choice and consent had been sought about daily living such as where they would like to have their meals and sharing bedrooms.

Management audits were limited and did not reflect several of the issues we observed, including monitoring of incidents and environmental risks. In addition, a number of safeguarding incidents had not been reported to the appropriate agencies in line with the provider’s own policies and procedures. This meant the provider did not have effective oversight of the service, and people were placed at continued risk of harm due to poor governance and a failure to follow safeguarding processes.

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

At the last assessment people were not provided opportunities to speak up about the care they received.

At this assessment we saw systems and processes were in place to allow people, relatives and staff to provide feedback.

Most people told us that they felt confident they could raise concerns and there issues would be acknowledged and addressed. Where people had made a complaint, most people told us that these had been resolved in a satisfactory manner.

The provider employed a diverse workforce and promoted workforce equality and staff felt they were treated with respect.

Staff told us they had been supported well since the change of manager.

The registered manager told us they had implemented staff initiatives such as employee of the month to further enhance workplace culture and support staff wellbeing.

There were a number of staff who were designated as champions in key areas such as dignity and dementia care. We saw evidence of this on the noticeboard where there were pictures of the staff and some information about the role.

Whilst we saw that staff meetings took place, we did not see how staff who were unable to attend were informed of minutes or given the opportunity to feedback to the registered manager.
 

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.

We found examples of inaccurate records, which undermined the reliability of care documentation.

During our assessment we asked the provider for immediate assurances about the actions they would take to ensure people continued to receive safe care, including support with medication and pressure care.

The lack of accurate and up‑to‑date records meant staff did not always have the essential information needed to deliver safe and effective care, increasing the risk of errors and avoidable harm.

Action plans lacked sufficient detail about what actions were required and the timescales for completing them.

They did not always correspond with audit findings, and several actions had passed their stated deadlines without review or completion.

There was little recorded evidence to demonstrate how identified actions were monitored, reviewed, or completed.

A new audit structure had been introduced; however, audits were not always completed in line with the framework, were sometimes left incomplete, and did not consistently identify the actions required to drive improvement.

At the last assessment, the provider did not have effective oversight of the service. Although some progress had been made, further improvements were required to ensure oversight was robust, embedded, and sustained.
 

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.

The registered manager told us they understood their responsibilities to make notifications to CQC when required and worked with the local authority quality monitoring team to improve care at the home.

Systems were in place to report and follow up on any safeguarding or incidents. However, we found several safeguarding incidents which had not been reported to the appropriate external agencies. This included notifications to both the local authority and CQC.

We discussed this with the registered manager and retrospective notifications were made.
 

The provider did not demonstrate a culture of continuous learning, improvement or innovation within the service.

Whilst there were limited systems in place to measure the quality of the service there was little evidence to demonstrate what, if any, action the provider had taken to address any concerns we identified as part of our inspection.

Processes had not been improved to ensure there was learning when things went wrong.

Opportunities to learn from incidents, feedback and best practice guidance were not utilised, meaning the service did not adapt in line with people’s changing needs and provide safe and person-centred care.

Where action had been taken, there was little oversight of the effectiveness of those actions.

Although we observed there had been some improvements at the service since our last inspection, the necessary improvements to the quality and safety of people’s care had not been consistently addressed or embedded, which did not demonstrate a commitment to learning and improvement.

This showed that leadership oversight and governance systems were not effective in driving sustained improvement.