Beeches 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 inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At the last inspection the service was in breach of regulations relating good governance. At this inspection, enough improvements had been made, and the provider was no longer in breach of this regulations.

This service scored 71 (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.

Staff at all levels had a shared vision and values as detailed in the employee handbook, ‘to provide a warm, friendly caring home for our residents. We aim to create a family atmosphere that makes everyone feel welcome, safe and loved.’

Staff and leaders demonstrated a positive listening culture and prioritised safe, high-quality, compassionate care. The registered manager and deputy manager clearly cared about people and their experience. The deputy manager said, “I want residents to be treated like my family.”

The provider ensured there was a clear focus on shared learning and improvement.

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.

The registered manager and deputy manager evidenced a good understanding of risks within the service. Concerns were discussed within management meetings and escalated to senior managers; in attempt to improve the safety and quality of care, and people’s experiences.

The registered manager and deputy manager took the time to improve their own skills and knowledge, by sourcing additional training and participating in forums, sometimes outside of their normal working hours.

Staff spoke positively about the registered manager and deputy manager, and they led by example. A staff member told us, “The registered manager is really nice, if you want anything they will help.” Another added, “It is a good, supportive team. The deputy manager is always there.”

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

The provider encouraged staff to raise concerns via regular meetings and annual surveys. The latest survey confirmed staff felt able to approach managers, and actions in response to concerns had been noted. For example, providing additional training, improving the weekly menu and increasing nursing staff numbers.

There was a good level of training in whistle blowing and staff confirmed they were able to voice concerns without fear of detriment. A staff member said, “Yes, I feel able to raise concerns. We have monthly meetings which we can join by teams. We discuss various issues.”

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 took action to prevent and address bullying and harassment. Staff had access to an employee handbook which included information around discrimination, bullying and how to complain.

Staff terms and conditions considered their rights, including their right to request flexible working.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support but did not always act on the best information about risk, performance and outcomes.

The registered manager, deputy manager and senior managers conducted audits to gather information and monitor the quality of care, but some issues were not rectified in a timely manner due to delays with equipment and resourcing. For example, there had been long standing faults with many of the fire doors, but at the time of our inspection these were only just being rectified by the provider. We also had concerns with the integrity of information in people’s care plans, and inconsistencies in recording the analysis of incidents and accidents; which had not been identified in checks or audits.

However, the registered manager and deputy manager had a good understanding of quality frameworks, recognised standards and best practice. They cascaded information to the team and where possible, implemented changes to improve outcomes for people living at the service.

The provider had implemented an electronic system, which supported arrangements for the availability and confidentiality of data.

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.

Staff worked in partnership with a range of local services and healthcare partners to share learning, promoting continuous improvement and better outcomes for people. The registered manager explained their involvement in registered manager groups and the deputy manager attended several forums.

The service was embedded in the community and was considered a valued partner. For example, the activities coordinator had built close links with the local library and primary school, organising events for people to enjoy alongside members of the community. One event had resulted in positive feedback from a local councillor.

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.

The provider had worked collaboratively with the local authority’s quality improvement team, to develop and improve the service since our last inspection. Staff gave several examples of how standards had improved. A staff member told us, “There are improvements to the cleanliness, the activities, the building and the staff. It’s all really good.”

The nominated individual acknowledged the positive changes the registered manager and deputy manager had made to the service, telling us, “There’s a solid team in place. We have been making small improvements weekly but need to look at refining things and making further improvements.”

The provider supported continuous learning and improvement across the service. Weekly management meetings focused on the standards of people’s care, their experience and quality of life.

However, there were still some concerns about the provider’s timeliness in responding to requests for additional resources or investment in improvements. Please see the ‘Safe environments’ and ‘Delivering evidence-based care and treatment’ sections of this report for more information.