The Beaufort Care Home

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 requires improvement because the provider was in breach of the legal regulations in relation to good governance. Some improvements were found at this assessment. We saw some audits, checks and processes had begun to identify where improvements across the servcie were needed. Plans to further develop training and record keeping on electronic systems was underway. However, despite some improvement, the provider remained in breach of this regulation. At this assessment the rating has remained 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 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.

We found a positive care culture that was being led by the management team. This was supported by the positive comments we received from people, relatives and external health professionals. Management told us they were supportive of each other and wanted to improve the experiences for those at The Beaumont. Staff recognised people’s individuality and each other’s strengths, skills and knowledge. One staff member told us , “Best thing I think is the unity amongst staff.” The manager told us they valued their staff team who wanted to do the best they could for people at the service. The management team including the senor regional managers were providing support to the home to strengthen the overall quality assurance systems which would help to continue to provide good care outcomes.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Through past inspections and a previous assessment, the provider has not always had effective oversight through leaders, to make sure the management and governance of the service was effective. Each inspection and assessment had rated well led as requires improvement and in 1 inspection, inadequate. At this assessment we found some improvements which we have reflected upon in this report and we have found some positive examples. However, further work was still required to ensure the provider met regulatory requirements and there are no legal breaches of regulation. We saw at this assessment managerial oversight had been increased, the benefits of which will be seen overtime but had not yet become embedded. We found staff felt supported by the manager and deputy manager. Staff told us the deputy manager supported them on the floor. One staff member said, “I feel able to ask the deputy for support, they have helped to hoist a person back to bed and help on the floor.” The manager explained the deputy manager had supernumerary hours which enabled them to support staff and model good practice. The deputy manager said, “It’s nice really because it gives me an opportunity to know the residents well.” However, the deputy manager said sometimes their time was taken up with other support such as GP rounds which affected how their hours were managed. They also told us this left limited time to review and upload people’s care plans electronically. The provider explained how they reviewed staff levels based on people's assessed needs and at the time of our visit, they had over staffed care hours by 17%. The provider felt this gave staff the time they needed to support people. Whilst staff felt there was a culture of collaboration and they felt generally listened to, staff felt the provider had not considered their feedback about required staffing levels based on the needs of the people using the service. The manager told us they had listened to staff and explained staffing levels were based on people’s dependencies.

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

Staff had confidence and opportunities to speak up if they had any concerns or feedback which included how to whistle blow. One staff member told us, “I would report to head office, police and CQC.” Another staff member said they would approach the deputy manager. The management team sought engagement with people, families and visiting professionals. Not everyone felt fully engaged in the service, however people and relatives we spoke with felt able to openly share their concerns. The manager displayed a ‘you said, we did’ poster in a communal hallway describing a recent change at the service. We saw suggestions had been reviewed by the management team to improve care quality.

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. Staff told us the provider had considered flexible working opportunities for staff working at the home. This included those staff members who were parents or soon to become parents. Staff shared shifts that had been accommodated to their needs and caring responsibilities. Staff told us this was done promptly by management. The manager told us they were proud of their staff team and valued their commitment.

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.

Previous inspections and assessments had found a quality assurance system that was not always effective or proactive to identify, monitor and sustain improvements. Following our last assessment where we found a breach of legal regulations in relation to the governance of the service, we told the provider they needed to be compliant by 24 January 2025. At this assessment, we saw some audits and actions had been taken, however some issues we identified previously remained. The provider remained in breach of the regulation. Where the provider was confident of improvements through some of their checks, for example in medicine management and fire safety, we found improvements were still needed. In some cases, quality checks when delegated to others had not identified some issues and the manager was not always aware of what was and what was not checked as part of those processes. The manager told us some checks had been delegated to staff such as nurses, however, there was no managerial oversight to ensure documents were reflective of the care and support people received.

Improvements to fire safety had been made and some improvement works were completed, however some fire doors were still not closing correctly, despite regular checks recording no issues and despite this being a known issue within the home. We found a lack of certainty of what consisted of ‘ALL HIGH RISK FIRE DOORS’ from those we spoke with and the required frequency of checking. The manager was not aware of what ‘high risk’ meant. We were eventually given a list of fire door locations and found fire door numbers did not match those written on each door. In 1 example, the number had been painted over. These issues identified by us had not been known by the manager or the staff member completing the checks.

The introduction of the electronic system running alongside paper records meant conflicting or a lack of important information being recorded. There was limited oversight to check what was being recorded and where gaps remained, for example in food and fluid monitoring. Where lessons had been learnt following a recent medicines error, those actions to prevent further errors went unchecked. We found staff were not always completing or signing the medicines record when administering patch medicines which could have potential to cause a further error. Daily walkarounds in the environment were completed by the manager but we found pest control measures had not been identified through these checks. Following our feedback, the manager took action to resolve this.

Speaking with senior managers, the manager and deputy manager, we did recognise the work and improvements that had begun. Senior managers were committed to continuing to strengthen the quality assurance processes. Managers were open and honest with us about the challenges with the transitioning processes of computerising care records. There were plans to increase staff training, confidence and knowledge to ensure people’s plans of care were updated.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Feedback from visiting health professionals was positive and described a service that was responsive to people’s needs. One comment was, “Staff appear to know the residents very well and can spot signs of deterioration early. They ensure a set of observations have been performed before escalating a resident who they think is unwell.”Relatives told us they were kept updated about any changes related to their family members overall health and welfare. People told us family members and friends could visit them without restriction. Some people had families take them tout of the home on trips. The manager told us they had access to a minibus so plans were being made to get people’s ideas on trips and days out in the local and wider community.Local communities, schools, faith groups were encouraged where possible to maintain important links with local and wider communities.

The Provider's quality assurance systems and processes require further improvements to ensure quality checks are effective and embedded in the service.

We have written examples in this report where similar issues identified at the last assessment remained. Through conversations with managers and senior managers we heard them taking responsibility for improvements we identified and discussed with them during this assessment. We could see there was improvements to some of the quality assurance processes but, in some cases, these were not timely enough or in other instances, had not eradicated ongoing issues such as the quality of what staff recorded and what managers recorded by way of checks. In one new example of how lessons were learnt following a medicines error, those steps to prevent reoccurrence were not monitored so we could not be confident actions were effective, and that learning had been taken and shared.

Staff said there had been some improvements since our last visit such as the decoration around the home and some people’s bedrooms were refurbished. Staff felt not enough improvements had been made around the level of staffing needed to meet the needs of the people living at the service.

The provider had put in place an electronic care planning system. Most staff said they felt confident using the system however, they were recording on 2 separate systems, 1 electronic and 1 paper based. The 2 systems sometimes had contradicting information. Some areas of the system had not been fully embedded or used such as when recording people’s medication and there was contradicting information from different managers around whether everyone using the service had been put onto the electronic system or not. This meant we were not assured systems in place were effective. We were told other homes had transitioned onto this new system, but it was unclear if there was any learning from that to support The Beaufort in its transition. The provider had acknowledged this and was arranging further training for staff.