Archived: Beeches Care Home (Nottingham)

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 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.

This service scored 61 (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.

The providers ethos read, “Caring with kindness.” We observed staff to carry out their duties in line with the provider visions and values.

The provider and wider management team demonstrated an understanding of the challenges faced at Beeches Care Home. The provider explained they had been working to rebuild a team that worked effectively following a period of uncertainty and high staff vacancy. The provider held transparent staff, resident and relatives’ meetings, whilst we saw some examples of action taken as a result of these meetings, families told us they did not feel everything was taken on board and acted upon.

At the time of the assessment the home was being supported by the senior management team as the home did not have a registered manager. People and their families told us they were confused about who the manager was.

We found that whilst there was a daily managerial presence in the home, who were all trying to make improvements, there were still risks and issues they had not identified and addressed. Staff felt that every day was different in the home when it came to leadership.

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

Staff told us they felt like the could report anything to any of the management team and they were confident they would deal with it appropriately. Staff were also aware of how to raise a whistleblowing concern if required.

The provider was currently in a recruitment drive to reduce the number of agency staff; we noted fair and inclusive recruitment practices.

The management team had held a number of staff meetings and huddles over the past few months, minutes of these demonstrated an encouraging and inclusive approach rather than accusatory or discriminatory.

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

The management team were open to feedback and addressed concerns we identified in a prompt and responsive manner. However, the ineffectiveness of their reactive risk management and lack of quality oversight meant the risks and issues we identified they had not been aware of despite the governance measures they had in place.

Some quality audits had been completed and actions taken, however they had not picked up the concerns we identified and audits were not being carried out regularly enough to maintain an effective oversight of the home.

The provider understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement. The provider understood their responsibility to work with external stakeholders and agencies, this included appropriate referrals, completing information requests and engaging with areas for improvement.

Families we spoke with said they had been to some relatives’ meetings and felt although management listen, not everything was taken on board and acted upon. Residents likewise had some meetings, but with limited action evident.

The provider 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.

Due to issues within the home this year the provider had focused on improving the quality of basic care delivery, understandably, rather than innovation or research.

Whilst some learning processes were in place, such as a monthly learning meeting, quality did not always improve following identified actions. For example, in July it was identified that documentation was an issue and this continued to be an issue during our assessment.