Clarendon Beechlands

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

At our last inspection we rated this key question inadequate. The provider was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Since the last inspection, a new registered manager had been appointed and had brought about significant positive changes to the service. This meant the provider was no longer in breach of Regulation 17. The new registered manager had followed the provider’s policies and processes, which meant they had good oversight over the service as a whole. The culture of the service had vastly improved, and people and staff were now alert, engaged and communicated well with inspectors. People, relatives and staff were confident they could raise any concerns with the new registered manager, and that these would be listened to and acted upon. All risks to people and staff had been reassessed and processes had been implemented to mitigate the impact of these risks. Care plans were detailed and descriptive for staff to follow, and audits were used as a tool for continuous improvement within the service. .

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.

Staff told us culture of the service had improved significantly since the appointment of the new registered manager. A staff member said, “Things have improved big time since [name] has become the registered manager.” Staff also told us they appreciated the registered manager coming in at different times to spend time with staff on each shift.

The registered manager now held regular meetings for people who lived at service, to listen to their feedback and suggestions for improvements.

Staff were extremely complementary about the current registered manager and acknowledged the hard work that had gone into improving the service. One staff member told us, “We have come a long way since the last inspection, and that is down to having a different manager.”

The registered manager was confident in following the provider’s internal auditing processes to assess the quality of care being delivered, and used this as a tool to make improvements where necessary.

Staff explained that people living at the service were now confident to speak openly and raise any concerns or suggestions they had. Staff said, “[The registered manager] wants to listen to you and helps you if you need her to.” Staff also felt comfortable raising concerns they had identified and felt assured these would be actioned.

The registered manager understood their role in relation to addressing concerns from both people and staff members. Staff knew who they could speak to in the absence of the registered manager. The provider had a whistleblowing policy in place and we observed posters around the service to provide staff with the relevant contact details.

The registered manager understood the multiple benefits of having a diverse workforce. They said, “We have a multi-cultural workforce. It is so important because everyone is different, and everyone has strengths and weaknesses. All staff are treated the same, no one is treated differently for any reason. We have zero tolerance to abuse against staff or people.”

The provider had policies and procedures in place, and risk assessments were completed when staff needed to wear certain items of clothing or jewellery under protected characteristics. The service also offered some flexible working arrangements to staff members.

The registered manager had a sound understanding of their role and associated responsibilities, and had displayed efficiency, tenacity and compassion in making changes to the service. Relatives also recognised the positive impact the change in management had on the service. One told us, “The name of the manager is [name], I think [name] is very professional compared to who was there before. The residents come first. I have total trust in her confidentiality.”

The provider kept contemporaneous records for people who lived at the service. Known risks were responded to promptly, and layers of support from the regional manager, associate director and nominated individual ensured there was continuous oversight of the service. The nominated individual held governance meetings, and the registered manager regularly held team meetings with staff.

People experienced care that was joined up and collaborative with other professionals. One next of kin said, “[Registered manager] was helpful, polite, willing, and really keen to listen. I felt the transition for [person] to move to Clarendon Beechlands was managed really well.”

Other leaders within the provider gave an explanation of how examples of good practice at a service are regularly shared amongst other services within the group so they can all benefit from this.

We observed one person who was going out to a medical procedure supported by staff member. When they returned, there had been recovery advice provided to the person, and staff were quick to cascade this information to the registered manager and other staff members.

The registered manager explained a recent quality assurance process they had participated in with the Local Authority. The registered manager told us that the officer from the Local Authority had made a few recommendations, and based on this, had immediately put together an action plan ensuring all of the recommendations were covered within the plan.

The registered manager acknowledged that there would always be learning and improvements to be made to the service, despite the significant and positive changes which had already taken place. They told us of some changes they wished to make to the service in the coming months. They said, “I am looking at [one of the lounge areas], people here like music and I want to turn that room into a social, gaming and entertainment room. In the garden I am looking at adding allotment plots. I always want [the service delivered] to be of a high standard.”

Regular staff and resident meetings were held to listen to suggestions from those who knew the service best.