Beaconsfield Residential 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 good. At this assessment the rating has changed to requires 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.

The service was in breach of legal regulation in relation to the governance of the service and informing CQC of notifiable incidents.

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 service 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 manager held a meeting with the staff team to agree service values, and discussed how to ensure these values were upheld, in November 2024. This needed time to be reviewed and embedded into practice. There was no evidence closed cultures was discussed as part of this process.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.



Processes and policies were not always followed and implemented by leaders. For example, the service did not always follow the provider’s policies in relation to smoking, infection prevention and control, managing risk and safe recruitment.

Social care and health professionals were positive about the improvements the management team had made. Throughout our inspection, leaders were open and honest about the improvements that still needed to be made and were motivated to learn and improve the service.

Staff were confident that immediate action would be taken if any concerns about people or practice were to be raised.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. People and their relatives told us the manager would act on their concerns in an appropriate way. However, there was a lack of regular engagement with people and their representatives which had a strong focus on supporting people to thrive, develop skills and have new experiences. The manager told us they would look into this with people.

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 the manager was approachable and would act on any concerns raised with them. We observed a positive culture during our onsite inspection.

The service 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 failed to ensure statutory notifications were submitted to CQC in line with regulations. We identified 3 safeguarding incidents had not been notified to CQC. Statutory notifications inform CQC of notifiable incidents and help us to monitor services we regulate.

Systems and processes were not operated effectively to ensure the service was safe and people were receiving high-quality care. The provider’s governance processes were not robust and were not used effectively to monitor the quality of the service, manage risks and drive improvement. This placed people at risk of harm. Systems were in place to support the manager to improve and develop the service. However, audits were not in place for some areas such as staff recruitment files and people’s care records. The audits in place were not completed effectively and did not drive improvement. We found concerns in relation to IPC, managing risk, medicines management and safe recruitment.

The manager was working with the local authority to make improvements to people’s records. The management team were responsive and took some action during our inspection to strengthen some audits and input audits where there were none. The service did not have a registered manager at the time of our assessment. The manager intended to apply to become the registered manager to ensure the provider met their registration requirements.

Staff supported people in the least restrictive way possible, however, people were at risk of harm because staff did not always have the information they needed, to support people safely. The ethos, attitudes and behaviours of leaders and care staff did not fully ensure people using services led confident, inclusive, and empowered lives.

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 and their relative’s confirmed people were supported to access health and social care professionals as they needed. The manager told us it was important for them to ensure they were open and transparent when working with other professionals. We received positive feedback about the manager from several health care professionals who were involved with the service. One professional told us, “I have found the manager responds appropriately to any feedback, advice or guidance from myself and colleagues. The manager is always proactive and remains focused on improving the home environment for their residents. She acknowledges any concerns or feedback and seeks solutions and ways to rectify or improve things.”



We found leaders had not always worked with and engaged people, their representatives and staff to build a culture that focused on enabling people to enjoy their lives.

The service 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.

Leaders spoke passionately about the need for continuous learning to drive improvements for the service. They described a strong desire for improvement and shared their plans to continue improving the service. However, their systems and processes were not always operated effectively to support this desire.

The provider had taken learning from their involvement with the local authority and have been making improvements to the service. Although the provider had systems and processes in place to identify actions to drive improvement, they were not always effective. For example, some audits lacked detail and therefore failed to drive improvement.