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. 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.

The provider was in breach of legal regulation in relation to governance at the service.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The culture experienced by people was not always consistent. Whilst warm and caring interactions were observed and feedback about staff was positive, support was task-focused and centred around routines rather than the person. This reflected the limited time staff had to spend with people.

One staff member told us, “We can chat during personal care. We don't have loads of time.”

Most people only received a shower once a month. When asked why, one staff member told us, “I think it's become a habit”.

The provider had compassionate and inclusive leaders; however, they did not always have the skills, knowledge and experience required to ensure robust systems and processes were in place to provide effective oversight of the service.

Leaders did not always maintain effective oversight of the service. For example, they had not consistently monitored required actions identified through external audits or ensured emergency evacuation plans were fully up to date. Although leaders showed a commitment to improving the service, they did not always have a clear understanding of people's day-to-day experiences. This meant opportunities to identify and address concerns were missed, increasing the risk of issues affecting people's safety, wellbeing and quality of life were not recognised or acted upon in a timely way. As a result, they could not be assured people consistently received care that reflected their needs.

However, we observed the registered manager led with compassion and care. They spoke positively about people living at the service and demonstrated a commitment to supporting both people and staff.

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

Staff said that they felt able to share their views and raise any concerns they may have. One staff member told us, “If I have any concerns, I can raise it directly with staff. If necessary, I can raise this with the manager instead. She is supportive.”

Another staff member explained how they could raise concerns in their supervisions.

There was a suggestion box for people to feedback anonymously if they wished.

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 service had recruited a diverse staff team, and staff told us they felt valued and respected by the manager. Staff completed equality and diversity training, and the provider's policies supported an inclusive approach.

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.

The provider’s systems and process to monitor the quality and safety of the service were not always effective, therefore, the provider remained in breach of legal regulations in relation to the governance of the service. Audits, both at provider and management level, did not identify the issues we found during this inspection. These included deficiencies in care planning and record keeping, fire safety and environmental risks, and a lack of assurance that people were receiving safe, person-centred care.

A recent IPC audit indicated the surfaces and floors in the kitchen were clean, and found no issues with expired food, contrary to our observations. Care plan audits failed to identify a number of the concerns we found including insufficient record keeping and a lack of detailed guidance for staff on how to meet people's individual needs. Auditing processes had not identified that many people were only being offered a shower approximately once a month, resulting in a lack of oversight of whether personal care was being provided in line with people's preferences and needs.

An external fire risk assessment completed last year identified the need for a designated safe location for charging hoists. This action had been marked as complete; however, during our inspection we found a hoist being charged close to a fire exit

A vacant deputy manager position left a gap in the management structure and placed additional pressure on the registered manager. As a result, the effectiveness of quality monitoring was reduced, as there was limited capacity for this.

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.

Staff worked well with other organisations. External services were made available for people to use, such as a chiropodist and a hairdresser. Referrals were also made where necessary, such as to the Speech and Language Therapy (SALT) team.

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.

Ineffective quality monitoring systems meant leaders had not always identified areas for improvement and learning which impacted on the quality-of-care people received. While leaders were responsive to the issues raised and shared a commitment to make improvements, this did not always happen in a timely manner. For example, further concerns relating to food safety were found on a subsequent visit after initial concerns were raised.