Beckoning House Limited

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.

This is the first assessment for this service. This key question has been rated 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.

During our assessment of this key question, we identified a breach of the legal regulation in relation to good governance. This was because we found concerns around the effectiveness of the provider's quality assurance and oversight systems and processes.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. The registered manager recognised improvements were needed to ensure governance and leadership was more robust and effective in managing the day-to-day monitoring and assessment of the quality of the service and to ensure it was always safe and met people’s needs. People using the service may have experienced inconsistent, inequitable, or unsafe care due to the absence of a clear vision, inclusive culture, and effective leadership systems.

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

The registered manager was managing the day to day running of the service and they acknowledged changes were required to make improvements to the service. The provider did not ensure that all leaders consistently demonstrated the organisational culture and values, nor did they always possess or apply the appropriate skills, knowledge and integrity to lead the service effectively and transparently.

The service had policy and processes for staff to follow on ‘whistle blowing’. The registered manager had developed a listening culture where staff felt they were available for them to talk to. This meant staff felt supported, valued and confident to raise concerns or seek guidance, which contributed to a positive working environment.

Staff told us they had regular supervisions. A staff member told us “The manager carries out regular supervision and we also have observations where they just turn up and observe us.”

There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act.

The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. The audits carried out by the administrator lacked detail and were mostly a tick box exercise and did not identify the shortfalls we found. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided. Care plans and staff files were not being audited regularly. Staff meeting minutes did not include action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. There was a lack of monitoring by the registered manager, who did not demonstrate appropriate management oversight of the service. The model of care did not meet the CQC guidance for ‘Right Support, Right Care, Right Culture.’ The registered manager had not kept themselves up to date with the requirements and knowledge for this model. The provider did not implement effective governance or oversight systems, which meant people were exposed to avoidable risks.

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 person’s care plan did not contain information about involvement with other professionals or any community partners. There was no evidence in the person’s care plan of medical referrals or appointments.

The registered manager was not part of any other organisation or local forum to support service development. We did not receive any feedback from health professionals.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The registered manager understood improvements were needed, they encouraged staff to discuss and share ideas for improvement and innovation. The registered manager did not keep a formal record of lessons learnt however, lessons learned were discussed during staff meetings.

The registered manager was aware they had more work to do to ensure all processes were communicated clearly and embedded to support learning and innovation.