Beechwood

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 at the service.

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 provider’s statement of purpose set out the aims and objectives for the service to ensure people had positive experiences and received high quality care. Staff understood their roles and responsibilities. Their interactions with people and with each other, reflected a positive and person-centred approach to care.

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.

People, staff and relatives spoke positively about the management of the service. They described the deputy manager and registered manager as ‘approachable’ and ‘supportive.’ One staff member said, “The managers are very good, they are supportive, understanding, approachable and very encouraging of the staff.” Senior managers were regularly on site providing clinical support and oversight.

People, staff and relatives told us they felt confident in raising any concerns or suggestions with the manager, knowing they would be listened to and acted upon.

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

Management were visible in the service and operated an open-door policy for people, staff and relatives, which we saw was utilised.

Staff were aware of the whistleblowing policy and felt any concerns they raised would be listened to and dealt with.

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 provider employed a diverse staff team including different ethnic backgrounds and genders. Staff meetings and supervisions showed staff were included in decision making.

Staff spoke of an inclusive culture where there was good teamwork and support for each other. Workforce well-being schemes and reasonable adjustments were available to and utilised by employees.

The provider did not have effective systems to ensure governance processes were successfully and accurately implemented. This increased the risk of harm to people living at the service.

Governance systems were ineffective in ensuring quality and safety. Although audit processes existed, they failed to detect or resolve key issues identified during our assessment. Where problems were noted, there was insufficient evidence that corrective actions were completed.

We found environmental and care-related risks were not consistently identified or mitigated. Care records were often inaccurate or outdated, failing to reflect people’s current needs. Medicines management was unsafe, with errors not addressed through governance checks.

These shortcomings indicated that existing quality assurance systems were not robust. Strengthening governance processes is essential to meet regulatory requirements and maintain safe, effective care.

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.

Care records demonstrated effective partnership working with a range of healthcare and social care professionals. This collaborative approach ensured people’s care was well coordinated and responsive to their changing needs.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Systems intended to support ongoing learning and improvement were ineffective. Our assessment identified significant shortfalls that had not been detected or addressed through the provider’s quality management processes.