Beige Healthcare Services

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 provider was in breach of the legal regulation relating to effective governance.

This service scored 62 (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.

Leaders worked with people, their relatives and staff to build a culture that focused on enabling people to enjoy their lives.

The registered manager said they were mentoring a new staff member who was completing their induction and had not worked in adult social care before. The registered manager shared their values and emphasised the importance of engaging with people to respect their rights and understand their needs and challenges.

However, there was a lack of vision and strategy for the service. Staff were not aware of the visions and values of the service.

The registered manager was visible and available. They led by example, modelling inclusive behaviours, open and cooperative relationships.

The registered manager advised, “I think the 1 key strength we have in regard to service delivery, people feel comfortable to speak to me if they need to, and staff, I have a great relationship with them.”

Staff provided positive feedback about the culture of the service and attitude of the registered manager.

However, due to the registered manager providing a lot of hands-on care they were unable to develop the service and focus on driving improvements including effective governance.

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

Due to the registered manager being so visible, regularly seeing people and staff when attending visits and always being contactable, people had developed a trusting relationship with them where they felt comfortable providing honest feedback.

However, there was no evidence to show feedback had been used to drive improvement. There was a lack of evidence of action taken in response to concerns or feedback given. For example, there were no meeting minutes, no supervision logs, no feedback forms and no communication or complaint records.

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.

The staff team were from a range of diverse backgrounds. Staff reported being treated fairly and equally. Where staff had requested flexible working arrangements, the service had supported this. One staff member told us, “[Registered manager] has been very understanding and supportive.”

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. There was a lack of evidence of effective governance.

There were no formal records of supervisions, staff meetings or competency assessments/spot checks to check the safety and standard of care. While people told us they could provide feedback and concerns were addressed there was no formal feedback records or review meeting minutes. No training matrix was in place, and the registered manager had not identified or addressed the fact that 1 staff member’s training was in need of updating. Policies in place were not specific to the service and policies were not followed in relation to record keeping.

Important records in relation to recruitment were not available and care plans were not up-to date.

Formal quality assurance systems including audits were not in place to measure and improve support delivered to people.

We have asked the provider for an action plan in response to the concerns relating to governance. 

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.

The registered manager was very proactive at working in partnership with any local organisations on people’s behalf. For example, religious groups.

People were supported to attend or engage with the local community for example by being supported to appointments or having flexible care calls to they could attend community commitments.

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.

There was no evidence that staff were supported to prioritise time to develop their skills around improvement and innovation. There was no clear strategy for how to develop these capabilities. There were no meeting minutes, supervision records, induction records, appraisals, or probation records to show that staff were encouraged to contribute to improvement and innovation initiatives. No additional training or guidance was sought to improve staff knowledge of a person’s individual diagnosis.

The service was not involved in any schemes, awards, research or projects. Technology had not been used creatively or innovatively to improve outcomes. Policies and procedures required improving.

Following feedback from this assessment the provider has been proactive at addressing the shortfalls we identified. They advised that they are more focused to put things in place and that as the service grows the registered manager can step away from providing hands on care and focus on learning, improvement and better governance.