42 Beeston Drive

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• 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

We assessed 7 quality statements in the well-led key question and found areas of good practice and concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Our rating for the key question has remained requires improvement. We identified one breach of the legal regulations. Audits and checks had not identified failings we found during the assessment, including issues with people’s care records, risks to people, health and safety checks, environmental safety and staff supervision. The management team acknowledged the improvements required in these areas and had taken actions to address some of the concerns identified during the assessment. Inconsistency of managers at Beeston Drive meant staff received inconsistent leadership, which had an effect on staff morale. This also had an impact on the quality of support, oversight and ensuring completion of audits and checks. The management team spoke openly about the challenges of inconsistent management and actions required to make improvements. Relatives and staff worked in partnership and collaboration. This included ensuring relatives were involved in appointments and planning of any changes in care. Relatives felt staff were engaged and attentive. However, some changes had occurred with staff leaving and concerns were raised by relatives of changes of management and poor communication from senior leaders.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were able to demonstrate an understanding of the values of the organisation and we observed this through their practice when supporting people. We found an open and honest culture and the management team demonstrated a commitment to addressing the shortfalls identified through the assessment.

The provider had a detailed Statement of Purpose which set out the providers aims and values. The vision and values of the organisation was also shared with people through the service user guide. The service user guide was available in accessible formats.

Staff did not always receive support from capable, compassionate and inclusive leaders due to inconsistent management arrangements. There was no registered manager at the time of our assessment. Managers in post were new to the service. Staff spoke positively about the new appointments, however, also told us they were frustrated at the lack of consistency, as this was having an impact on staff morale. We were told, “I wouldn’t recommend working here at this time due to the instability. There has been so much change in a short space of time.” We shared staff feedback with the management team who told us they were aware of the staffs’ feelings.

The lack of a consistent management team had impacted on the quality of the support and the completion of quality processes. The nominated individual shared a plan with the inspector detailing the management arrangements to mitigate risks in this area. The inspector also supported the daily management of the service. However, a more permanent solution needed to be found. Attempts to employ a new registered manager had been unsuccessful and recruitment was ongoing.

Staff told us they were aware of the whistleblowing process and felt confident to speak up. One staff member said, “I know who I could go to if I needed to raise any concerns. I do feel I would be protected.”

The provider had a detailed whistleblowing process in place for staff to refer to when raising concerns. The nominated individual was able to describe the processes they follow when concerns are raised.

The nominated individual was able to describe the process they would follow if concerns were raised. No concerns about equality, diversity and inclusion were raised to us by staff during this assessment.

Policies and procedures were in place to ensure equality, diversity and inclusion was promoted and respected throughout the workforce. The provider had developed a workforce development plan which was regularly updated. Systems were in place to reward and recognise staff. Staff received recognition through provider bulletins and systems were in place to award monetary rewards where staff head been considered to have gone ‘over and above’ their usual role, or for other initiatives, such as good attendance.

The management team spoke openly about the challenges the lack of a registered manager had on the quality of the service. The nominated individual also discussed additional management resources were in place to support people and staff. Staff also told us the lack of a stable registered manager had impacted them.

Systems to monitor the quality of the service were not consistently robust or effective, failing to identify several issues we noted during our assessment. These included gaps in care plans, risk assessments, personal information, health and safety checks, aspects of medication records, an expired DoLS, as well as the environmental concerns we highlighted to the provider. There was also a lack of clear guidance for staff to follow in a medical emergency for one person, though this shortfall was immediately addressed when raised. Additionally, the systems were not sufficiently robust to ensure that staff always received supervision and competency checks in line with policy. The provider had developed an overall improvement plan for the service, which identified several necessary improvements and was subject to regular review by the management team.

Relatives told us that staff worked in partnership with them. This included planned visits, health appointments and involving them in different aspects of the person’s life. However, concerns were raised over the inconsistency of the changes in management. This meant that relationships were maintained through the established staff at Beeston Drive.

Staff and leaders were able to provide examples of partnership working and how they worked collaboratively with health professionals. For example, when making referrals to the local authority following events which occurred or when accessing medical support to meet the needs of people.

Where feedback was received, external partners gave mixed feedback. Some feedback discussed concerns over manager oversight at Beeston view, as well as morale of staff. Another professional told us, “Great communication between the team and myself, and overall I was very impressed.”

Systems were in place to demonstrate when partnership working had taken place. This was recorded in people’s support plans as well as through reporting systems for accidents and incidents. The provider used an external partner to undertake quality visits at the service. The most recent report had generated actions to improve the service. However, limited progress had been made at the time of our assessment.

Staff felt they could share their views about the service. One staff member told us the chief executive had recently attended a team meeting and listened to staff feedback on the difficulties they had experienced due to the inconsistent management arrangements. Some staff told us they had recently had a supervision where they could talk about their role. The provider was open and transparent throughout the assessment, was open to the feedback given and demonstrated a commitment to making the improvements needed at the service.

Systems were in place to demonstrate learning and identifying improvement. Due to the management inconsistency, records of communications were maintained between support staff and family members to keep people updated. The new management team was starting to build these relationships and recognised this as an important area of focus. The service user guide described to people who they would be consulted with and how they could contribute and share their views about the quality of the service they received.