Beaconville 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 service did not always operate effective systems and processes to support the delivery of safe and high-quality care. The service was in continued breach of legal regulations in relation to good governance.

This service scored 46 (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 always have a shared vision, strategy and culture. The provider’s systems and processes, such as the business continuity plan, were not always adapted to the service. The manager was not fully aware of the information the provider had included and told us some parts were not suitable for the service. For example, the business continuity plan identified specific training the staff needed to deal with different challenges in the service, however, this training had not been completed by staff and the manager and clinical lead told us it was not relevant for the service.

The provider’s systems and processes failed to identify some important events that must be notified to the Care Quality Commission through a statutory notification, this included a police incident and a serious injury.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to governance.

The management team understood the context in which they delivered care, treatment, and support. The manager had applied for registration with the Care Quality Commission to become the registered manager. The manager told us the provider was supportive; however, there was no evidence of provider audits or reviews. The manager was visible within the service and led their team by example. Most staff were positive about the recent management changes.

A staff member told us, “The last couple of months here has been a real positive shift and (Manager’s name) has stepped up and her communication is really good with the staff, it feels like a very open door, you do not feel you are bothering them which is really nice.”

The service did not always foster a positive culture where people felt they could speak up and their voices would be heard. The service was not able to evidence regular feedback had been collected from people, relatives, staff and professionals. Some staff members we spoke with felt leaders did not always listen to concerns and take action. However, some staff felt they could raise concerns, and action would be taken. Relatives told us they felt confident in raising concerns to the manager, comments included, “Haven’t had any worries, but I’m confident that they would take me seriously.”

The manager told us, and records confirmed, concerns had been raised, actioned, and lessons learned. This had been communicated to staff and relatives of the person who had raised the concern. The service had a website and open-door policy to allow people, relatives, staff, and professionals to raise feedback.

The manager told us the service valued diversity in their workforce and worked towards an inclusive and fair culture. We received mixed feedback from staff. One staff member told us, “I think that everyone is treated fairly and equally, and I have not heard of anyone not being listened to.” Another staff member told us, “Staff are treated fairly and equally and we do communicate well, before I was afraid to speak English but the staff have helped me.” However, we were also told, “I don’t think we are treated equally.”

The manager was aware some staff felt this way, and was taking action to change the culture.

The provider did not always have effective governance systems in place to identify and drive improvement. Audits were completed monthly by the management team but failed to identify all the shortfalls identified at our assessment. Staff file audits were completed monthly, but did not identify they were not assessing whether a new staff member was of good character and had the qualifications for the role before starting working with people. Some care plan audits were completed but did not identify records were not always accurate, contemporaneous and complete. These records lacked guidance or provided staff with inaccurate guidance on how to care for a person, putting people at risk of harm.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe care and treatment, governance, staffing, fit and proper persons (recruitment).

The manager understood their duty to work in partnership with other services, such as the GP. Most partners we gained feedback from were positive about the service. One professional told us, “Beaconville continue to work excellently with us by engagement with our service. Nurses send over appropriate clinical information to enable us to triage their referrals.”

The provider did not always focus on continuous learning, innovation, and improvement across the organisation. The provider did not always monitor progress and take appropriate action without delay where progress was not achieved. This meant there was a continued breach of regulation relating to good governance.