Becket House Nursing 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 as Good.

At this assessment 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 57 (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 embedded in the service. Although regular communication with the staff team took place during team meetings and one to one supervision there was a clear focus upon tasks and what was expected of staff. Opportunities were missed to develop an open and positive culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Also, a staff survey had been completed within the last 12 months, but there was no evidence of analysis and follow up actions from the survey’s findings. Staff told us they felt part of a team and felt supported by the registered manager.

The registered manager did not always have sufficient oversight of all areas of service provision. This led to issues not always being identified and acted upon promptly to ensure people received care in line with legal requirements. The registered manager was experienced and knowledgeable in their role but some of their systems and processes were not effective and needed to be improved. They were responsive throughout the assessment and began to make improvements when concerns were brought to their attention. We received positive feedback from staff who told us the registered manager was approachable and supportive. A staff member told us that the registered manager was present around the home, checking that people were okay.

The provider fostered a positive culture where people felt they could speak up and their voice be heard. Staff told us they felt supported and able to raise any concerns they had.

The leadership team promoted a culture where staff were encouraged to speak up and share their views. Staff told us they felt able to raise any concerns and felt these would be listened to and taken seriously. Staff knew where to find policies, procedures and information necessary for their roles.

The provider valued diversity in their workplace. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider did not have effective governance systems in place to assure themselves of the quality and safety of care provided to people. Audit and quality assurance of key areas of service provision did not identify the concerns we found during the assessment. This meant issues were not always followed up, rectified and monitored appropriately in order to drive continuous improvements. We found concerns in the areas of incident investigation and safeguarding, medicines processes, mental capacity assessments, care planning and the environment. People were potentially placed at risk of receiving unsafe care or care which did not meet their assessed needs. Opportunities to learn lessons and make improvements to people’s care may have been missed. We did not find any harm had been caused to people. The registered manager responded promptly when issues were brought to their attention and provided evidence of the improvements they were implementing.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with relatives and relevant professionals for the benefit of people receiving care and support. There was evidence that the service worked with local GPs and other health and social care teams.

The registered manager told us that the service had visits from local schools throughout the year and a volunteer supported the home weekly.

The provider did not always focus on continuous learning, innovation and improvement within the service. Processes to learn lessons when things went wrong and make improvements were not embedded into practice, which meant there was a higher risk of the same thing happening again. For example, there were systems in place to record accidents and incidents such as falls when they occurred, but no evidence of management analysis taking place to review if there were any themes or patterns developing, or lessons to be learnt. Opportunities were missed to discuss these with the staff team so that people’s care could be developed and improved.