Beckfield House Residential 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 inspection we rated this key question requires improvement. At this inspection the rating has remained required improvement.   This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.  At our last inspection the provider was in breach of legal regulation in relation to their governance. At this inspection not enough had been done and the provider was still in breach of this regulation.

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 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.  People, staff and relatives all told us they felt supported by the registered manager and management team and there was an open and honest culture at the service.

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. However, leaders and the systems they used were not always effective in identifying where there were issues with medicines and care documentation. For example, the service had several audits relating to the management of medicines. However, there were a limited number of peoples medicines records audited ever month which meant they had not identified all issues when following their own quality assurance processes.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.  Staff told us they were encouraged to speak up and their feedback was always acted upon.

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. All staff we spoke with said they were treated fairly by the registered manager, management team, provider and other staff.

Although the service had clear responsibilities and roles, their systems and auditing processes were not effective in ensuring accountability or good governance. They did not always follow national guidance to ensure safety of medicines for people at the service or ensure Mental Capacity Act 2005 principles were followed. The service had auditing processes in place for medicines which were not effective in identifying issues found during our assessment. For example, a small sample of 3 people’s medicines records were audited every month. This risked there being errors in people’s medicines administration that would not be identified by the services audits. The service operated a resident of the day process which allowed a review of each care plan at least monthly. However, there were also processes in place for care plans to be audited by the managment team. The managerial audits had not always taken place. Care plan reviews and audits had not identified where information was missing such as specific health and social care needs. The registered manager had put plans in place for both them and the deputy manager to review 3 care plans a week, in order to improve and update care records where needed.

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. People at the service benefited from the partnerships the service had built with local health services such as G.P, district nurses, physiotherapy and mental health teams, as well as the links they had made with the local community such as the parish council, library and local primary school.

The service did not always have the audits in place to identify opportunities for continuous learning, innovation and improvement across the organisation and local system. However, following our inspection the registered manager said they would be taking action to review their auditing systems. Time was needed to embed any changes they made to ensure they could constantly encourage creative ways of delivering equality of experience, outcome and quality of life for people. These changes will actively contribute to safe, effective practice and research.