Beaumont Manor

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.

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 demonstrated an approach to care which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, although plans were in place to make a number of improvements at the service, as set out in the provider’s own development plan, there was not yet a clear shared vision, strategy and culture as this work was in its infancy. Improvement works already identified by leaders needed to be more fully realised, particularly in relation to safety issues such as medicines, and metrics for success were still to be identified and tested. More time was needed to implement and embed these changes. This meant there was a disconnect between the service delivery and future vision. A relative told us, “It’s a home where the environment is lovely but not quite clear why the rest of it doesn’t gel with what you expect.”

Leaders understood the context in which the provider delivered care, treatment and support. They embodied the culture and values of their workforce and organisation. We found those in management positions had the skills, knowledge, experience and credibility to lead effectively, and did so with integrity, openness and honesty. However, there had been some management instability at the service which was now being resolved. At the time of our assessment, a new deputy manager had recently started and was being supported by the wider provider group which had included an interim manager. A new manager joined the service towards the end of our inspection. Whilst positive feedback was shared about new management, people and their relatives told us there had been an impact on driving forward improvements without a consistent leadership team in place. A relative said, “[Beaumont Manor] are very aware they have had some leadership issues there and some interim managers there as well, this impacts on communication.” At the time of our assessment, the new management team needed more time to continue developing positive relationships with staff, people and relatives.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A relative told us, “It is well run, a very open culture. We are allowed to go anytime day or night, they are not trying to hide anything, it is great.” There was an open and transparent culture which was modelled by leaders. A duty of candour policy was in place, and we saw people received an apology when things went wrong. Staff also had access to an independent whistleblowing telephone helpline should they wish to raise any concerns anonymously for any reason.

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. Processes were in place to support the workforce, and we received largely positive feedback about support for staff. One staff member told us, “I feel [interim manager] and [deputy manager] are both really helpful and supportive and it feels like things have improved. It feels like they have been helpful regarding health conditions.” The Regional Director told us staff could access free counselling services, and confirmed, “All the homes have mental health first aiders.” Staff had regular team meetings to support inclusion, and leaders told us they planned to also introduce evening meetings to ensure the involvement of the night shift team.

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. Whilst systems were in place for oversight, this needed development and enhancing in a range of areas including care plan audits, medicines oversight, and analysis of themes and trends in accidents, incidents and safeguarding matters. Some policies also needed to be reviewed, as they were not personalised to the service. The provider was aware of the action required and told us they had invested in 3 new electronic systems for medicines management, care planning, and auditing (including incident recording), which all would interface with one another and improve oversight going forwards. Legal and regulatory requirements were met in relation to statutory notifications, which is information providers must share with the CQC about any serious injuries, safeguarding concerns or the outcomes of Deprivation of Liberty Safeguards (DoLS) applications.

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. However, this work still needed time to embed. We received positive feedback from professionals who worked with the service. We saw the service hosted regular meetings for people living at Beaumont Manor and their relatives to share information and seek their views. However, some relatives expressed concerns that changes had not always happened in a timely way following their input. A relative said, “[Beaumont Manor] send the [meeting] minutes out and they are useful, but they go over the same things, the food and asking for carers for night time. We have been talking about both of them for over a year now.” We were also informed there had been repeated delays to the introduction of a keyworker system. Another relative told us, “We would like monthly meetings with relatives so that we can discuss things at the earliest point – we propose these should be scheduled for the whole year.”

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. Whilst there were clear pockets of good practice in relation to the quality of care provided, some fundamental safety issues were outstanding at the time of our assessment. This meant the provider was not yet in a position to demonstrate innovative practice over and above a solid foundation, due to some gaps and inconsistencies which still needed to be addressed. Leaders were clearly committed to improvement work at the location and told us they would continue to invest in this going forwards.