Archived: Beaconsfield Residential Care Home

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. 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 good governance at the service.

This service scored 39 (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.

Delivery of care was not based in a strong person centred and enabling culture. We found only a few examples of how people had been supported to develop their daily living skills and encouraged to work towards living more independently. People’s human rights were not embraced and there was not a focus on how they could enable people to live a good, ordinary life as part of their community.

We asked about the organisation’s vision and values. The manager told us, “The (local authority) quality team came to do visions and values, it is an area we need to revisit and get everyone on same vision.” The manager told us they assessed the culture of the service by using observations and feedback from colleagues and people using the service. There was no evidence closed cultures were considered and no records to indicate how the culture in the service was monitored.

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

There has been no registered manage in the service since 4 August 2024. The provider had a manager in post who was applying to be registered.

At the last inspection we identified 4 breaches of regulation. We issued enforcement action. At this inspection we identified 4 continued and 3 new breaches of regulations. This indicated some development in leader’s skills and knowledge were required and indicated they did not always implement the provider’s processes and policies. For example, leaders had not ensured the provider’s policies in relation to non-smoking, recruitment infection prevention and control and managing risk were followed placing people at risk of harm.

The provider did not always foster an open culture in which people felt they could speak up and their voice would be heard. Some people felt they could speak up but did not always feel that their voice would be heard. One person told us they had asked for information but still had not received an answer.

The manager told us they had an open-door policy. The provider had a whistleblowing policy in place. However, it only directed staff to raise concerns with the manager or provider, there was no detail of how staff could escalate any concerns outside of the service if they felt their voices were not heard. This meant staff may not know how, or feel comfortable, to raise any concerns they had in relation to their manager or the provider. A robust whistleblowing policy is designed to ensure staff can raise their concerns about wrongdoing or malpractice within the service without fear of victimisation, subsequent discrimination, disadvantage, or dismissal.Following the inspection the provider told us the whistle-blowing policy had been partially updated following their last inspection, but they had accidently missed out some information. They also told us they had placed notices around the home containing further information.

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.

Staff told us they were treated equally and fairly. The manager gave us an example of how they provided for staff’s dietary needs relating to their religion.

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 failed to assess, monitor, and mitigate risks relating to the health, safety, and welfare of service users and failed to ensure records were relevant and up to date. Systems and processes in place failed to identify the concerns we found at the inspection in relation to risk management, infection prevention and control, medicines management, recruitment, notifiable incidents and person-centred care. The lack of accurate, complete, and contemporaneous records increased the risk of people not receiving the correct care and treatment and increased the risk of harm. People continued to smoke in the service without sufficient controls measures in place. The provider had failed to make required improvements and people remained at risk of fire.

Robust action had not been taken to address shortfalls and limit the impact it had on people’s care. At our previous inspection in February 2025, we found although the provider had systems and processes in place to identify actions to drive improvement, these were not always effective. Some audits lacked detail and therefore failed to drive improvement. We found the same concerns at this inspection.

The provider did not store all records securely in line with the principles of the General Data Protection Regulation (GDPR). Some archiving was stored in the loft which had 2 access points from a person’s bedroom. These were not locked. The manager told us the person had not attempted to go into the loft space. However, there was a risk confidential information could be accessed by people who were not authorised to do so.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners; however, this collaboration did not always lead to improvement.

The provider has been part of a Large-Scale Safeguarding Enquiry (LSSE) for a year and has been supported by the local authority to make improvements. Improvements had not always been made and where concerns had been identified improvements had been slow and areas requiring improvement was usually identified by external professionals. The failure to have robust systems in place to identify concerns and drive improvement put people at risk of harm.

The provider told us they wanted to work towards continuous learning and improvement across the organisation. However, their overall ambition was limited by the lack of established risk and effective quality monitoring systems. This meant they might not always be aware of shortfalls to enable prompt improvement and learning

There were continued concerns from the previous inspection with limited improvement and learning. Ongoing failure to implement good quality and manage risks across the service and make improvements to meet good standards and regulations.

The provider’s objective for delivering care for people with learning disability and autism did not incorporate the principles of ‘Right care, right support, right culture’ guidance. Therefore, people had not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.