Bearwardcote Hall Residential Home

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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 inadequate. At this assessment, the rating has improved to requires improvement. This reflects the progress made by leaders in addressing some of the concerns identified previously. We found evidence that steps had been taken to strengthen management and leadership arrangements and improve oversight of the service. However, leadership and governance processes were not yet consistently effective, and further work was needed to ensure the culture and management systems fully supported the delivery of high-quality, person-centred care.

This service scored 61 (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 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.

Following our previous inspection, improvements had been made across the service and there was evidence that the provider had taken action to address the concerns identified regarding the culture of the service. Staff told us communication had improved and told us they felt supported by managers and leaders. We saw evidence that leaders had taken steps to promote a more open and positive culture, including creating opportunities for staff to raise concerns, share feedback, and contribute to service development.

Leaders had also worked to communicate the service's vision and values more clearly, helping staff to better understand their roles and responsibilities in achieving positive outcomes for people using the service. In addition, systems for monitoring performance, reviewing progress, and identifying areas for improvement had been strengthened.

These changes demonstrated a commitment to improving the culture, leadership, and governance of the service. However, many of the improvements were relatively recent and had not yet been fully embedded across all areas of practice. Further time and sustained oversight were needed to ensure the positive changes became part of everyday practice and resulted in consistently positive experiences for both staff and people receiving care.

While improvements in culture, communication, and leadership were evident, the provider needed to continue embedding and sustaining these changes to ensure a consistently open, inclusive, and supportive environment for all.

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.

Recruitment, induction, supervision, and training processes had been strengthened, helping to ensure staff had the knowledge, skills, and confidence required to carry out their roles safely and effectively.

We received mixed feedback from relatives regarding the visibility of the management team. One relative told us, “Management just sit in the office with the door shut, very rarely see them.” Another relative described the management team as approachable and said they operated an open-door policy, making themselves available to discuss any concerns or questions. Despite these differing views, staff spoke positively about the support they received from leaders and felt able to approach them for advice and guidance.

Overall, leaders demonstrated good oversight of the service, with systems in place to support staff development, monitor quality, and promote positive outcomes for people receiving care. Improvements had been made since the previous inspection, and leaders had identified further areas for development. They were actively working towards embedding these changes into the service to ensure improvements were consistently applied and sustained over time, resulting in positive outcomes for people and staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. At this inspection, we found improvements had been made in relation to speaking up, staff engagement, and the provider's response to feedback. Staff told us they knew how to raise concerns both within the service and externally if required. Staff were able to describe the whistleblowing process and were confident about escalating concerns appropriately.

The management team had taken steps to ensure staff understood their responsibilities by regularly discussing speaking-up processes during staff meetings. Information about how to raise concerns was accessible to staff, and leaders checked staff understanding to ensure they knew how and when to report issues.

We also saw evidence that leaders were making better use of staff feedback. Staff surveys were completed and reviewed, and actions had been taken in response to feedback received. For example, improvements had been made to the environment and equipment available within the service. Staff told us they felt their views were being listened to and that managers were more responsive to issues raised.

The provider had also strengthened communication with staff through regular meetings and updates, helping to ensure concerns, learning, and service developments were shared more effectively. While some of these improvements were relatively recent and required ongoing embedding, there was clear evidence that leaders had taken action to create a more open and responsive culture where staff felt supported to raise concerns and contribute to service improvement.

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. At this inspection, we found improvements in the way the service promoted equality, diversity, inclusion, and staff wellbeing. Staff demonstrated a better understanding of these topics and had access to relevant training to support inclusive and respectful working practices. Leaders had taken positive steps to create a more supportive and inclusive culture. Staff told us they felt respected and valued within their roles and were confident that concerns would be listened to, taken seriously, and acted upon appropriately. Recruitment practices had also been strengthened, and leaders demonstrated a commitment to developing a diverse and supportive workforce. Staff had opportunities to raise concerns through supervisions, team meetings, and other feedback mechanisms, and there was evidence that leaders listened to feedback and implemented improvements where needed.

At this inspection, we found improvements had been made to governance, management, and oversight arrangements. Since the previous inspection, the provider had implemented an action plan to address the concerns identified and had taken steps to strengthen systems for monitoring quality, managing risks, and supporting staff.

Leaders had improved the use of audits and action plans to identify areas for development and drive improvement. There was evidence that issues identified through their monitoring were being reviewed and acted upon more effectively. Communication with staff had also improved, helping to increase understanding and consistency across the service.

Systems relating to record keeping, confidentiality, and data protection had been strengthened, and staff demonstrated a better understanding of their responsibilities. Improvements had also been made to emergency planning arrangements and management oversight, helping to ensure continuity of leadership and support within the service.

Workforce management processes, including recruitment, training, supervision, and staff development, had become more structured, providing leaders with greater oversight of staff performance and compliance. We also found evidence that incidents, safeguarding concerns, and regulatory requirements were being monitored more effectively than at the previous inspection.

While these improvements were positive, many had been implemented relatively recently and required further embedding and sustained oversight to ensure they became established practice. As a result, additional time was needed to demonstrate that the changes were consistently effective and delivering sustainable improvements across all areas of the service.

The provider had made improvements in working with external professionals and had taken action to address concerns identified at the previous inspection, engagement with people and their relatives was not yet consistently embedded. Further work was required to ensure people were routinely involved in developing, reviewing, and evaluating their care, and that care records consistently reflected their goals, preferences, and desired outcomes.

At this inspection, we found some improvements had been made in the service's approach to working with external partners. The provider had maintained regular communication with CQC following the previous inspection and provided updates on the progress of their action plan and the improvements being implemented.

However, whilst improvements had been made in partnership working with external professionals, engagement with people and their relatives in care planning was not yet consistently embedded. Records did not always demonstrate that people and those important to them had been involved in developing care plans, setting goals, or reviewing outcomes. The provider had recognised this as an area for development However, these improvements were still being implemented and were not yet consistently evidenced at the time of inspection. Therefore, further embedding was required to demonstrate sustained improvement in this area.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

While systems for monitoring performance and learning had improved, these were not yet fully embedded throughout the service. Whilst improvements had been made across many areas of the service, including the environment, communication, governance arrangements, staff support, and the planning of people's care, these changes were still being implemented and embedded into everyday practice. Leaders had taken positive action in response to the concerns identified at the previous inspection and there was evidence of progress and improved oversight. However, many of the systems and processes introduced were relatively new and required further time to demonstrate they were consistently effective and capable of delivering sustained improvements. As a result, further embedding of these changes was required.