Beeton Grange

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 good. At this assessment the rating has remained as good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 and their communities.

Staff understood the importance of recognising their workplace was actually someone’s home. The registered manager told us, “I’ve told staff we are here for service users’ wellbeing. We are working in their home. If someone wants to get up at 1am in the morning and have a cup of tea, then they can, it’s their home.” Staff understood people’s needs, what was important to them and recognised the positive impact the improved living environment had on people. The registered manager was keen to ensure support was provided to people to enable them to improve their health and wellbeing. Weekly one-to-one meetings between people and the staff who supported them enabled the service to keep on track with people’s ever-changing needs and what was important to them. People saw themselves as a family group and staff recognised that. Staff told us they felt supported by the management team. Staff meetings took place to provide staff with the opportunity to have their voices heard.

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.

A member of staff described the ‘Lifeways Choice Values’ and how they were constantly reminded to ensure their care delivery was reflective of those values. They told us, “The manager always reminds us to be caring, honest and have empathy. I have been at this service for a short time, and it is reflective of what those values are. We listen to them [people living at the service] when they are talking and look at how much we can help them have their independence as well.”

We found the management team were responsive to our findings during the assessment and where improvement was required, were receptive to this feedback and responded immediately. Staff told us they felt supported and listened to. Staff understood their roles and responsibilities and told us they worked well together as a team. Staff talked of the change over from paper records to the electronic care planning system. Additional support was provided to staff during this period to smooth the transition for all.

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

Staff told us if they had any concerns, they would raise them with the management team and felt they would be listened to. A relative told us they felt the staff were supportive and approachable. Staff were aware of the provider’s whistleblowing policy and knew what actions to take if they had concerns regarding the conduct of others.

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.

Action had been taken to ensure staff were representative of the population of the people using the service. The service supported people from a variety of cultural backgrounds and the staff group reflected this.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance systems in place. They did not always act on the best information about risk, performance and outcomes or share this with others when appropriate.

We found the provider had a variety of quality assurance systems in place including a 3-tier auditing system to monitor the service in the form of daily, weekly and monthly compliance checks. These checks and balances were carried out by staff, the registered manager and the area manager. However, not all audits were robust and had failed to identify a number of concerns that were raised during the assessment. We found the assessment and management of risk was not always thorough or comprehensive. Audits had failed to identify environmental issues that were found during the assessment. The management team responded immediately to the concerns raised and action was taken to address these.

As part of the provider’s ‘digital transformation’ plan, the service was in the process of introducing an electronic care planning system. Paper-based care plans were still in place for some support plans, but arrangements were in place to move these across to the electronic system within the next couple of months. Staff were supported with additional training to use the system and were positive about its use. A deputy manager led on supporting staff in this area. A member of staff told us, “[Name of electronic recording system] gives us everything we need. The transition was smooth and we did some face to face training.” We were told action was being taken to ensure the recording of all accidents and incidents were moved from the existing system to the new electronic system, which would make it easier for staff to record such events.

The registered manager told us they ensured good practice through staff training and observing the culture in the home. The registered manager developed their own learning through attending a variety of management meetings and forums. Policies and procedures were in place to support staff. Staff reported they understood their roles and responsibilities and changes in practice were communicated with them.

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.

Systems were in place to ensure information was shared with other healthcare professionals. The service was supported by a variety of professionals including the local GP practice and mental health support services. The registered manager told us, “We have weekly calls from the advanced nurse practitioner from our GP practice to discuss any issues. If we need someone to come out they would do that.”

The provider had systems in place to help focus 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, but the implementation of some of these systems was not robust. For example, following a safeguarding concern, despite actions being taken, no system had been put in place to assure the provider that staff were following the guidance provided. Auditing systems in place, designed to assist management when identifying errors and potential lessons to be learnt, had failed to identify a number of areas found during the assessment.

The management team were receptive to all feedback shared during the assessment process and responded immediately to rectify any areas of concern that were identified. Surveys had been completed and action plans were in place to address and act on the feedback received.

Systems were in place to review accidents and incidents and provide staff with a number of prompts to action, following each event. Information was analysed for any lessons to be learnt following these events. Monthly risk management reports were produced which included additional oversight from a psychologist.