Beechwood Care 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 inadequate. At this inspection the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At our last inspection the service was in breach of legal regulation in relation to governance at the service. At this inspection, whilst some improvements had been made recently, the service remained in breach of this regulation.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider did not have a clear, shared vision, strategy or culture that promoted transparency, equality, inclusion, engagement and positive outcomes for people. Frequent changes in management had resulted in a lack of stable leadership and staff described a culture where systems for improvement had not been consistently established. An activities co-ordinator told us, "Need stability and good leadership," reflecting concerns about the lack of continuity and low staff morale.

Although some improvements had recently been introduced by the interim manager, who had been in post for 4 weeks at the time of the inspection, these were not yet embedded or reflected in a consistently shared culture across the home. Positive developments included daily flash meetings, increased oversight of wounds and weights, greater involvement of relatives in care reviews, and a revised activities programme developed with relatives. However, these changes were at an early stage and there was insufficient evidence they had resulted in sustained improvement.

Strategic leadership and governance arrangements had not been effective in identifying, managing and addressing risks. Governance systems, including audits, care oversight and risk monitoring, had failed to identify to concerns relating to medicines management, maintenance and infection prevention and control. Staff described previous attempts to raise concerns and seek support from senior leaders but did not always feel listened to or supported. One staff member said they had "asked many times to speak to the right people and to put something in writing." Regional oversight had been intermittent and leaders had not maintained sufficient oversight of the quality and safety of the service.

As a result, the provider could not demonstrate a clear strategic direction or effective leadership capable of driving and sustaining the improvements required to ensure people consistently received safe, high-quality care.

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.

Leadership capacity and capability were significantly compromised. The service had experienced repeated changes in management and key leadership positions, including the deputy manager and clinical lead, were vacant. At the time of the assessment, the interim manager had been in post for only 4 weeks and oversight was heavily reliant on this role, with limited evidence of effective support from the wider provider. Although some improvements had been introduced, leaders had not established sustainable systems, clear accountability arrangements or consistent guidance for staff.

Staff feedback reflected the impact of unstable leadership and a lack of inclusive and supportive management. Staff described uncertainty about expectations, low morale and a culture that had been negatively affected by continual changes in leadership. One staff member told us, “Changing managers all the time, more adjusting. We don’t know what to do.” Another described previous leadership as creating “a very toxic environment” and not providing the guidance needed for staff to carry out their roles effectively.

Leaders at service and provider level had not demonstrated the skills, knowledge or oversight required to lead the service effectively. Risks relating to people's safety and wellbeing were not identified or addressed promptly despite some concerns having been raised previously. During the assessment we identified unsecured PPE stations, fire door deficiencies and unsafe moving and handling practices, which had not been effectively acted upon through existing oversight arrangements. These findings, alongside failures identified in other areas of the assessment, demonstrated that leaders had not maintained effective oversight of the service or responded appropriately to known risks.

While some staff acknowledged positive changes under the interim manager, there was insufficient evidence that capable, compassionate and inclusive leadership had been established or embedded across the service. The provider could not demonstrate leadership arrangements that consistently promoted a positive culture, supported staff effectively, or ensured safe, high-quality care for people.

People did not always feel they could speak up and that their voice would be heard.

Staff did not always feel able to speak up with confidence that their concerns would be listened to and acted upon. Staff described a previous toxic culture and told us they had attempted to raise concerns, including asking to speak to the appropriate people and putting issues in writing. However, provider records showed that concerns about the culture within the service had not been fully recognised by senior leaders during previous oversight activities. While the provider had recently introduced a dedicated 'speaking out at work' email and some staff described improvements under the interim manager, there was insufficient evidence that an open and transparent culture had been embedded. As a result, leaders could not demonstrate that all staff felt consistently empowered to raise concerns, challenge practice or contribute to improvement.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had not consistently created a positive, inclusive and supportive culture for staff. Although some improvements had been introduced in recent weeks, the evidence showed workforce morale, support and engagement had been negatively affected by a prolonged period of unstable leadership and inconsistent management practices.

Staff described a culture where they had not always received the guidance, support and leadership needed to carry out their roles effectively. One activities co-ordinator told us that previously, "One manager spoke to you like something on the bottom of your shoe," while other staff described uncertainty about expectations and a lack of consistent leadership. Feedback indicated that frequent changes in management had contributed to low morale, poor team cohesion and a culture where staff did not always feel supported to succeed in their roles.

The provider had some workforce support arrangements in place, including supervisions, appraisals, group supervision sessions and training opportunities. Some staff also spoke positively about the interim manager and described recent improvements in communication and leadership. Several staff said the service had "been the best in the last 4 weeks" and told us they felt the interim manager was approachable and willing to listen to concerns.

Despite these improvements, the positive changes were recent and remained heavily dependent on the interim manager's presence. Inspection findings identified examples of poor accountability and inconsistent practice, including tasks not always being completed and occasions where people's basic needs were not prioritised during mealtime observations. Complaints and feedback from relatives also reflected frustrations about previous inaction and poor communication. Records reviewed did not demonstrate a consistent organisational approach to promoting staff wellbeing, equality and professional development across the service.

While leaders had begun to take steps to rebuild staff confidence and improve culture, there was insufficient evidence that a positive, inclusive and equitable workforce culture had been embedded. Improvements remained fragile, and leaders could not yet demonstrate that staff consistently experienced the support, guidance and accountability necessary to deliver high-quality care.

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.

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 meetings, audits and provider oversight processes were in place, these had failed to identify, assess and address significant concerns across the service.

Inspection findings demonstrated widespread governance shortfalls, including breaches of infection prevention and control, poor oversight of environmental risks, ineffective monitoring of medicines management and incomplete care records. We found visibly dirty floors, inappropriate laundry storage and unsafe storage of personal protective equipment. Internal audits had not identified gaps in medication records, including omissions relating to topical and 'when required' medicines. Fire safety checks were completed. However, records did not demonstrate that identified risks had been effectively addressed. For example, concerns relating to fire doors that did not seal correctly remained unresolved, potentially compromising people's safety.

Record keeping and oversight arrangements were inconsistent and ineffective. Care records contained gaps and inaccuracies. Further concerns included incomplete fluid and repositioning charts and governance tools that did not consistently record actions, ownership or timescales for improvement.

Provider-level oversight was not sufficiently robust to identify or respond to these concerns. Governance reports contained inconsistencies, including quality assurance scores that did not total 100%, and evidence of follow-up actions was not always clear. Throughout the inspection, inspectors repeatedly sought assurance regarding how provider oversight had identified concerns and driven improvement. While the provider had introduced monthly governance meetings, mock inspections and action plans, these measures had not yet demonstrated sustainable improvements or provided assurances risks were effectively identified and managed.

The accumulation of governance failings across multiple aspects of the service demonstrated that leaders did not consistently act on information about risk, performance and outcomes. As a result, the provider could not demonstrate effective governance arrangements capable of maintaining safe, sustainable and well-led 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.

The provider worked with a range of external partners to support people's care and treatment; however, partnership working was inconsistent and often reactive rather than proactive. Evidence showed leaders engaged with the local authority, social workers, community mental health teams, GP services, dietitians and a nutritionist to support people's health needs and address concerns. External agencies were also involved in areas such as medication audits and safeguarding matters.

Some improvements in communication and engagement had been made under the interim manager. Relatives described better communication and 1 family member told us, "The communication is good." There was evidence of greater involvement of families in reviews and discussions about people's care. However, this positive experience was not consistent. Some relatives told us they were unaware of formal meetings relating to their family members or were unclear about care plan reviews and decision-making processes.

Leaders did not always demonstrate a consistent understanding of their responsibility to collaborate effectively with partners to improve outcomes for people. Partnership working often appeared focused on responding to issues as they arose, rather than using established relationships to drive improvement and prevent concerns from escalating. Previous local authority escalation processes highlighted concerns requiring intervention, and provider-level assurance regarding how learning and improvement were shared and monitored was limited.

Records did not always demonstrate that information provided by external partners had been effectively embedded into care planning and oversight processes. For example, community access arrangements were not always complete or sufficiently monitored. Questions also remained about how governance actions arising from feedback and partnership activity were followed through and evaluated.

While there was evidence of constructive relationships with some partners and recent improvements in communication with relatives, partnership working was not consistently coordinated, embedded or used to support continuous improvement across the service.

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

The provider did not have an effective approach to learning, improvement and innovation. Although some improvement initiatives had recently been introduced, there was limited evidence that learning had been embedded into practice or resulted in sustained improvements for people using the service. Leaders had implemented measures including wound clinics, weight clinics, additional medicines oversight, mock inspections, staff training, revised cleaning schedules, daily flash meetings and plans to develop a sensory room. However, inspection findings demonstrated that significant concerns remained across multiple areas of the service.

Evidence gathered during the assessment showed that previous learning and improvement activity had not consistently translated into safer or better-quality care. We identified concerns relating to mealtime experiences, hydration support, environmental risks, record keeping and governance oversight despite ongoing monitoring, audits and action planning. These findings indicated that lessons were not consistently learned, embedded or effectively monitored to ensure improvements were sustained over time.

Staff feedback reflected a culture where expectations, guidance and accountability had not been clear. Staff reported confusion around expectations, changing management approaches and uncertainty about how identified concerns were being addressed. This demonstrated that improvements had followed a prolonged period of inadequate leadership and support, rather than being part of an established culture of continuous improvement.

While provider oversight had increased in recent weeks, improvement activity remained largely dependent on regional management visits, external audits and newly introduced systems. Internal governance processes had not demonstrated sufficient effectiveness in identifying failings, learning from concerns or assuring that actions had led to meaningful change. There was little evidence of innovation, shared learning or proactive quality improvement activity designed to enhance people's experiences, outcomes or quality of life.

The provider could not demonstrate a culture of continuous learning and improvement. Systems remained reactive and focused primarily on responding to identified concerns rather than understanding underlying causes, embedding learning and driving sustainable improvements. As a result, leaders were unable to provide assurance that lessons from previous failings had been learned and consistently translated into improved outcomes for people.