Beech House Nursing 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 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 governance.

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 provider 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

The registered manager told us the provider’s vision and values was about individuality, giving people empowerment and involvement in their care planning. Staff we spoke with cared about empowering people and involving them in their own care and shared this vision. Leaders and staff were passionate about providing compassionate, person centred care to people.

The provider shared a positive message regarding meeting the needs of people and both staff and leaders acknowledged and were keen to improve the quality of care where concerns had been identified.

Not all leaders understood the context in which the provider 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 knowledge to lead effectively.

Leaders did not always prioritise appropriately to ensure the quality of the service met the needs of people safely. For example, actions on the fire risk assessment were not all complied with in a timely manner which meant there were unsafe staffing levels at night in the event of an emergency and the home environment was not always safe.

Statutory notifications were not always submitted to CQC for allegations of abuse due to the registered manager misunderstanding their regulatory responsibility. This was addressed immediately and those identified were submitted in retrospect during the course of the assessment.

Staff told us they had raised concerns regarding staffing pressures but did not always feel like leaders listened to them. Where staff and the registered manager had shared concerns regarding insufficient staffing levels at night, the provider had failed to increase staffing levels to ensure the continued delivery of safe care to people. After this was raised as a concern during the assessment, night staffing levels were immediately increased. The registered manager told us they were taking steps to recruit where they had identified gaps in staffing levels at other times.

However, the registered manager was visible for people, relatives and staff and they all knew who the registered manager was.



Leaders demonstrated a person-centred approach to care and were passionate about providing support that met people’s needs. The registered manager told us they were well supported by senior leaders and senior leaders regularly visited the home.

The registered manager was open and honest throughout the assessment and was proactive with ensuring actions were addressed with urgency.

The provider was not always proactive in fostering a positive culture where staff felt they could speak up and their voice would be heard.

Staff told us they felt able to approach the registered manager but they were not always confident their voices would be heard particularly around their concerns regarding working hours and insufficient staffing levels. However, staff were confident the registered manager would listen to them if they were speaking up about the welfare of people living at the home.

People and relatives felt they were able to speak up and were confident any concerns they raised would be addressed. Where things went wrong, apologies were given and people and relatives were told about any action being taken to prevent any future reoccurrence.

A whistleblowing policy was in place and staff knew where to find it.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse workforce. Staff who were recruited from overseas told us they had received support from the provider when they commenced employment and continued to do so in many ways such as in relation to transport and housing. However, staff told us they sometimes felt compelled to work additional hours due to low staffing levels and did not always feel supported when they wished to take leave from work.

People living at the home told us they had heard some staff being spoken to in a negative way by leaders at the home which they hadn’t liked.

The provider was not always proactive in ensuring all staff were given a voice and able to engage fully with them. Whilst staff did feel able to approach the registered manager, team meetings were infrequent. The registered manager told us this was due to most staff depending on provider transport to attend their place of work, so it was difficult to get staff all together. Staff did not always feel empowered that their suggestions would be listened to when they did raise their voice.

However, reasonable adjustments had been made to support disabled staff to carry out their roles well. Staff were given equal opportunity when being considered for additional training and more senior roles.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems in place to check the quality of care were not always robust. Audits were not always completed at a set frequency which meant the provider could not be assured any concerns were being identified in a timely manner and acted on. Quality checks failed to identify inconsistencies in care documentation or where safeguarding referrals and statutory notifications had not been made.

Quality checks of medicines were not sufficient to identify where there had been missed medicines or where protocols weren’t in place for ‘when required’ medicines. Infection Prevention and Control (IPC) audits failed to identify where cleaning records had not been completed.

Systems in place for the oversight of people’s clinical needs were not always effective. For example, where people required weekly weights or bowel monitoring, no checks were completed to ensure this had been done.

Despite formal audit processes not being sufficiently robust, leaders did involve themselves in the running of the home and engaged in a high level of informal oversight. The registered manager acknowledged that formal oversight could be improved and more consistent and told us improvements would be made going forward.

Systems in place enabled the service to take a proportionate approach to managing risk which meant people were able to receive person centred support. For example, clear risk assessments were in place to manage risk in relation to people regularly going on trips away from the home.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager told us about and we saw evidence of the provider’s involvement with the local community. For example, the home held a Christmas fayre involving both people living at the home and the local community which people enjoyed.

The provider was proactive in enabling people to access the local community. Residents told us how much they enjoyed accessing the local community and visiting local shops and pubs.

Staff and leaders collaborated positively with relevant commissioners and health and social care professionals to ensure people received joined up care that met their needs.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider did not always measure outcomes effectively to enable them to understand how to make improvement happen. As quality checks were not effective, they were not always able to analyse outcomes to ensure changes could be put in place to improve the service. This meant improvements were not always made when needed.

Where actions had been identified to improve safety at the home, the provider did not always learn from this and take action in a timely manner. For example, the provider failed to take all actions necessary to improve safety at the home following the completion of the fire risk assessment as they had failed to comply with concerns around night time staffing levels and had not completed other environmental changes required at the home within an appropriate timescale.

However, the provider engaged people and their relatives in questionnaires requesting feedback in order to determine where relatives thought improvements were required. Action was taken on this feedback. For example, when people provided feedback regarding meals, the provider arranged a trial day for people to try new meal choices.

When things went wrong in respect to people’s care, the registered manager shared learning amongst the wider staffing group to reduce the chance of reoccurrence.