Beechcroft

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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 2 quality statements in the well-led key question and found areas requiring improvement. The scores for these areas have been combined with scores based on the last rating, which was requires improvement. The assessment of these areas indicated areas requiring improvement, our rating for the key question has remained the same. Although we were assured information was used effectively to monitor and improve the quality of care, people’s care records did not always best evidence that care had been delivered as prescribed. However, the provider was actively addressing identified shortfalls at the time of our assessment. There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Systems were effective at managing risks to the quality of the service. Processes were in place to help ensure learning happened when things went wrong. People and staff told us they felt comfortable to speak up with ideas for improvement.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from managers demonstrated they had a good understanding of current risk within in the service and areas for potential staff development. Staff spoke positively about the management team and told us they felt supported in their role. Staff also told us how they felt communication in the home was effective and helped them keep up to date with people’s changing needs. Comments from staff included, “The managers are approachable, and I can talk to them, they are accommodating” and “[Manager’s Name] is amazing, and I will ask any questions all the time. Always there with an open door.” Staff also told us they felt the management promoted a positive culture, which was focused on person centred care. Comments included, “The manager promotes the idea for people to live as they want to live, they can do whatever they want and it's all person centred” and “The manager promotes us being helpful to people and to always give them choice and encourages us to do the job well.”

Processes were in place to help enable clear and effective governance, management and accountability arrangements. Although we were assured information was used effectively to monitor and improve the quality of care, people’s care records did not always best evidence that care had been delivered as prescribed. For example, where people required mobility aids, care plans did require further guidance for staff about what equipment should be used for that person. However, where shortfalls had been identified such as lacking information in care plans and quality of daily care records, audits had been effective of highlighting these issues. This information was used effectively to help monitor and improve the quality of care, and actions to address shortfalls were in progress at the time of our assessment. Required notifications were submitted to external organisations as required. There were robust arrangements for the availability and confidentiality of data, records and data management systems.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from managers and staff demonstrated an understanding of how to make improvement happen. People, their families and staff were involved in developing and evaluating improvement. Resident meetings and questionnaires were in place to help ensure people had a say in the running of the home and had a platform to feedback their ideas. The area manager told us how feedback from people had been sought about redecoration of the home and people had chosen the colours of the paint they preferred for the home. Feedback from both managers and staff also confirmed how lessons were learnt from when things went wrong to help further improve good practice. The area manager explained, “When an incident has occurred to help staff learn I will put it into document and talk about it in daily flash meetings to cascade to all staff.” A member of staff confirmed, “We [Staff] do learn from incidents, and we communicate via daily flash meetings, we are kept up to date.”

Processes were in place such as daily meetings and reflective sessions to help ensure learning happened when things went wrong. Staff told us they felt confident to put forward their views and ideas around improvement and innovation. One member of staff told us, “I feel confident to put ideas forward either in a meeting or on my own.” The registered manager explained how meetings took place with the provider’s other homes, including annual and regional meetings. This provided opportunities for further learning and best practice guidance to be exchanged. An accessible complaints policy was in place for people and their relatives. The registered manager also operated an open door policy for both people and relatives to feedback their views at any time.