Beechdale House Care Home

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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 three quality statements in the well-led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last assessment, which was requires improvement. The assessment of these areas indicated areas of improvement since the last assessment visit, our rating for the key question has therefore improved to good. There were clear and effective governance, management, and accountability arrangements. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours, and performance of staff. The systems to manage current and future performance and risks to the quality of the service took a proportionate approach to managing effectively. Data or notifications were consistently submitted to external organisations as required. Information was used effectively by the management team to monitor and improve the quality of care. Leaders implemented best practice guidance or equivalents to improve experiences and outcomes for people using services.

This service scored 75 (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.

The provider had given their full commitment to investing in the service. They were open and transparent in acknowledging their previous poor performance and were working hard on embedding and ensuring a robust improvement plan was actioned. The whole staff team gave positive feedback about the provider and registered manager, describing them as, ‘involved’, and ‘caring’. Our observations of their interactions with people and relatives during the day indicated they were dedicated to improvement. The provider told us, “I’m proud of the hard work of the registered manager and staff team; and personally invested in making the required improvements at the service.”

The provider had a service improvement plan in place, with allocated tasks and regular auditing being completed by the management team to assess progress. The provider had employed a full-time maintenance person to progress with the required works identified at our previous visit.

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.

All of the staff we spoke with told us how they had felt the service had improved since our last visit. One staff member told us, “It’s a massive difference, you can really tell how much things have changed.”

The provider ensured the systems and processes in place were effective. There was accident, incident and falls analysis in place. This meant the provider had the systems in place to identify themes and trends to inform them how to improve support and safety for people. There were management audits of medicines, infection control and care plans which meant the service had effective oversight, ensuring people were not placed at risk of having unmet needs. We reminded the provider and registered manager of their responsibility to ensure there were robust arrangements for the availability, integrity and confidentiality of data, records, and data management system. We observed two occasions during our visit where person identifiable information was left unattended when staff were busy with other tasks. Mitigation was given for these shortfalls, and the provider added a prompt to the daily handover for staff to remind them of the importance of ensuring confidentiality at all times. The provider and registered manager showed evidence of lessons learned and improvements implemented as a result of incidents that had occurred. The provider and registered manager had ensured they reported notifiable incidents to the CQC as required by law.

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.

Staff were encouraged to participate in a range of training to enable them to fully support people’s identified needs at Beechdale House. We saw from the training matrix that staff had completed all training required by the provider. The registered manager had enrolled the service on extra training, such as a falls research programme, to enable progression and innovation around falls management in the service.

The provider demonstrated a focus on continuous learning and embedding improvement across the service. Acknowledging previous shortfalls in the quality of care provided; the provider had ensured they now had robust systems in place to deliver a positive experience, and good quality of life for people. The provider had a plan in place to improve the living environment for people and ensure people’s care was safe and effective.