The Beeches 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 inspection we rated this key question good. At this inspection the rating has changed to 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 governance at the service.

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, 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.

Leaders did not always demonstrate effective oversight of the quality and safety of care provided within the service. While managers were visible, accessible and generally regarded by staff as approachable and supportive, governance arrangements had not been sufficiently robust to identify and address a number of concerns found during the inspection.

The provider did not always ensure leaders at all levels promoted an inclusive and equitable culture that reflected the values of the workforce and organisation.

Leaders at both service and provider level had not demonstrated sufficiently effective oversight, leadership or governance to ensure the service was operating safely and in accordance with people's needs. A number of risks to people's health, safety and wellbeing had not been identified, assessed or managed effectively through existing monitoring arrangements. For example, during the inspection we identified unsecured stairways that had not been subject to an appropriate risk assessment, alongside other environmental concerns that had remained unresolved despite presenting potential risks to people using the service.

These issues had not been recognised or escalated through routine audits, management checks or provider oversight, indicating weaknesses in governance systems and risk management processes. The concerns identified during the inspection were not isolated and were reflective of wider shortcomings found across multiple key areas, including care planning, medicines management, environmental safety and the application of legal frameworks. As a result, there was reduced assurance that people were being protected from avoidable harm and that the service was being managed in a way that promoted safe, high-quality and person-centred care.

Staff, people and relatives were able to speak up about concerns they had at the service. However, we could not be assured that issues within the service were always reported on in a timely manner or that leaders understood their role in identifying and acting on concerns. For example, we identified multiple issues with medicines management, but recent medicines audits did not identify these concerns.

As a result, although people and staff were able to speak up, there was limited assurance that concerns were always translated into meaningful action. This meant opportunities to learn from feedback, identify emerging risks and improve outcomes for people were not always fully realised.

The provider did not always promote an inclusive and equitable workplace culture. Some staff told us they did not always feel they were treated fairly and felt that favouritism could occur where multiple family members were employed at the service. This had the potential to impact staff confidence in the fairness and consistency of decision-making.

While many staff told us they enjoyed working at the service and described the management team as approachable, supportive and willing to listen to their views, not all staff shared this experience. Staff generally felt able to seek advice, raise concerns and discuss issues affecting their role; however feedback indicated that the provider did not always demonstrate a culture that fully promoted equality, fairness and inclusion for all staff members.

The provider did not 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.

Governance systems were ineffective in ensuring people received safe, high-quality care and support. Leaders and the provider had not established clear and effective systems of accountability, oversight and quality assurance. Although governance audits and provider oversight processes were in place, these had failed to identify, assess and address significant concerns across the service. This indicated that existing monitoring systems were not operating effectively in practice and did not provide leaders with a reliable understanding of the quality and safety of the service. As a result, opportunities to address concerns at an earlier stage and prevent deterioration in standards had been missed. This reduced assurance that people were receiving consistently safe, effective and person-centred care, and that risks to their health, safety and wellbeing were being appropriately managed.

During and following the inspection, we sought assurances from the provider regarding the concerns identified. The provider and service leaders responded positively and demonstrated a willingness to engage with the inspection process, seeking professional external advice and taking initial steps to address a number of the concerns raised. Their responsiveness and openness to feedback created opportunities for reflection, learning and service development.

However, while actions had commenced, many of the improvements required were at an early stage and had not yet been fully implemented, embedded or sustained in practice. As a result, there was limited assurance that these actions had led to lasting improvements or that governance systems were sufficiently effective to identify concerns, monitor quality and drive continuous improvement. Further work was required to ensure changes resulted in consistently improved outcomes for people and that leadership oversight was robust enough to maintain and sustain safe, high-quality care.

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.

Leaders did not consistently demonstrate effective partnership working to ensure people's needs could be met safely and that positive outcomes were achieved. We were made aware of examples where people had been admitted to the service despite leaders expressing reservations about whether their needs could be consistently and safely met within the services’ existing staffing arrangements, environment or resources. This indicated that admission decisions were not always underpinned by sufficiently robust assessment, consultation and planning. Effective partnership working should ensure relevant information is shared, risks are fully considered and services are confident they can meet people's needs before admissions take place.

As a result, there was a risk that people's needs were not always fully evaluated prior to admission, which could impact on their safety, wellbeing and overall experience of care. These examples demonstrated that leaders did not always use available professional partnerships and networks effectively to support decision-making and ensure people were only admitted when the service could provide appropriate care and support. Further work was required to strengthen partnership working and pre-admission processes so that decisions consistently reflected people's needs and promoted positive outcomes.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Some of the provider’s systems and processes required further development to ensure they were consistently effective in assessing, monitoring and improving the quality and safety of the service. This was evidenced by issues identified during our inspection that had not been identified through the provider’s own governance and oversight arrangements. These included concerns relating to safeguarding, care planning, risk management and managerial oversight. The provider was open and responsive to feedback throughout the inspection process and took prompt action to review records and strengthen governance and oversight processes.