Beulah Road

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 inspection, we rated this key question requires improvement. At this inspection, the rating has changed to good. This meant the service was now consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

Staff were supported by managers to deliver safe, person centred care and support to people in line with the provider’s vision and values for the service. Systems and processes had been designed in line with the vision and values and focused on people and meeting their individual needs. The registered manager routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles. Staff were supported by the registered manager deliver consistently safe, equitable, person-centred, and inclusive care and support to people based on the services own shared culture and values.

The service 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.

The care home had a suitably knowledgeable, and experienced registered manager who had been in post for several years and bought some much-needed stability and continuity to the service. People living in the care home, their relatives and staff working there were all positive about the leadership approach of the registered manager who they consistently described as approachable, friendly, and supportive. Typical feedback included, “The manager is always working in the care home and is very hands-on helping staff out on a shift.”

The care home remains without a deputy manager. We discussed this issue with the registered manager at the time of the inspection, and they told us an action plan had been agreed for a new deputy manager to commence working at the care home in the new year [2026].

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

At our last inspection we found the provider did not engage sufficiently with people's families. This represented a breach of regulations.

At this inspection we found the provider had improved how they engaged with the relatives of people living in the care home. This meant they were no longer in breach of regulations.

The care home had an open and transparent culture where people, relatives, external health and social care professionals, and staff were all encouraged to raise concerns without fear. The provider used a range of methods to gather people’s views about what the care home did well or might do better. The provider received regular feedback through various forums people could attend. The manager told us they explained the complaints process before people moved into the home. Staff feedback concerns on behalf of people or their representatives and to record them in their care notes.

The provider valued and listened to the views of staff. Staff were encouraged to contribute their ideas about what the service did well and what they could do better during regular individual and group meetings with their line managers and fellow co-workers. The provider had a ‘Speak up’ policy that was displayed in the registered managers office and accessible to all. Staff felt able to bring` things to the attention of the managers.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they were part of a diverse team, treated equally and fairly, and they felt able to speak up. Staff told us the registered manager was supportive and reported feeling cared for, respected, valued, and listened to by them. One member of staff said, “This is a fun place to work. We work well as a team, and I feel like a valued and respected member of it.” Another added, “We’re a culturally diverse bunch of staff working here but we all seem to work well together and mutually respect each other’s different ethnicities, race, faiths and culture.”

The registered manager understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity, and fairness in the workplace.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance, and outcomes, and share this securely with others when appropriate.

At our last inspection, the providers governance systems had failed to pick up and/or address all the issues we identified at the time in relation to management of safeguarding, risk, and staff training. This had placed people at risk of harm and represented a breach of regulations.

At this inspection we found the provider had made enough improvements to ensure their established governance systems were effectively operated and the service continuously meaning lessons and improved. This meant the service was no longer in breach of regulations.

Governance systems were used to regularly check and audit the quality and safety of the care and support provided at the care home. The outcomes of these checks and audits are routinely used to identify performance shortfalls which feed into action plans to continuously improve the quality and safety of the service people living at the care home received. Managers and staff demonstrated a good understanding of their governance roles and responsibilities in relation to assessing, monitoring, and managing the quality and safety of the service they provided.

The quality of information recorded and maintained in people’s care records, and records relating to the management of the service was sufficiently detailed, up to date and accurate.

The registered manager understood their responsibilities in relation to regulatory requirements around notifiable incidents. Our records indicated they continued to notify the CQC in a timely manner about any incidents and events they were legally required to. They also understood their responsibility to apply duty of candour and where appropriate, apologised when things went wrong.

We saw the service's previous CQC inspection report, which was easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider shared information and learning with partners and collaborated for improvement. Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. For example, multidisciplinary team members were all involved in helping staff develop care plans to meet people’s specific needs including, positive behavioural support, diabetes, and epilepsy risk management plans. The registered manager and staff also told us they worked closely with their local GP surgery and a psychiatrist to stop the use of ‘as required’ psychotropic medicines to modify behaviours considered challenging and develop less restrictive interventions to prevent or appropriately manage this risk.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice and research.

The registered manager understood the importance of having an open culture of learning and continuous improvement to ensure people consistently received high quality, safe care, and support. Audits and checks the provider conducted were routinely analysed to identify performance shortfalls and learn lessons, so the service could continuously improve. When lessons needed to be learned, the provider developed action plans which set out clearly what, how and when they needed to take steps to improve the service they provided people. Staff confirmed information about any lessons learnt and action plans developed as a result were always shared with them during individual and group supervision meetings with the registered manager.