- Care home
Beaufort Grange
Report from 30 September 2024 assessment
Contents
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
The overall rating for this key question is Good. At our last inspection we identified the providers quality assurance systems were not always identifying shortfalls found during our inspection. At this inspection some improvements had been made and the provider had an action plan that confirmed where improvements were still required to people’s mental capacity assessments We found monthly reviews of people’s care plans were not always identifying shortfalls such as where people needed a mental capacity assessment and if their personal evacuation plan and risk assessment were up to date. The registered manager confirmed some actions were taken straight away to update these shortfalls. Staff felt supported by the management team and the registered manager was working with external professionals and agencies to improve people’s care and support. Staff were encouraged to gain additional qualifications, and the registered manager promoted staff achieving their full potential. The management of the home was accessible to people and their relatives and positive feedback was provided from health care professionals who told us the care provided to people was to a very high standard.
This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.
Staff felt supported by the management and nursing staff. One member of staff told us, “I can go to the manager, clinical lead or regional director.” Another member of staff told us, “We are a brilliant team and we support each other.”
The registered manager confirmed they were working with staff to improve the service and people’s care such as following incidents and accidents and when improvements had been identified such as through complaints, audits and inspections. Daily meetings were an opportunity for staff to discuss new admissions, any changes to people’s individual needs and if there were enough staff on duty that day. Staff meetings were an opportunity to discuss any changes to people’s individual needs, and if there had been any complaints, incidents and accidents, wounds, and if any referrals were needed. The management team liaised with health care professionals when required including GP’s, tissue viability nurses, social workers and physiotherapists.
Capable, compassionate and inclusive leaders
The registered manager confirmed staff were supported to achieve their potential. This was achieved through supervision, training and qualifications. The registered manager confirmed they were undertaking additional qualifications to support them in their role as registered manager and staff within the service were also supported and encouraged to do the same. There was an employee of the month undertaken where residents were asked their opinion on the support provided by staff. The provider had a recognition scheme in place for staff where they had completed a certain number of years’ service.
The registered manager was open and transparent about the areas of improvement required within the service. They held various meetings with staff so that improvements could be made. Staff felt supported by the management team and able to raise any concerns should they need to. The regional director undertook quality assurance visits, and any actions identified were shared with the registered manager.
Freedom to speak up
All staff we spoke with felt the management were supportive and accessible and there were daily opportunities to raise any concerns should they need to.
The registered manager wanted staff to raise concerns with them so there was a culture where they could make improvements required. The home had a ‘Speak up champion’. This was where staff could go to raise concerns should they feel unable to do this directly to the management.
Workforce equality, diversity and inclusion
Staff felt supported by the management of the service and it was a nice place to work. One member of staff told us, “I like working here, it’s nice here.” The home had a diverse workforce and staff were supported by the provider and registered manager to achieve their potential through training, support and supervision. Staff could access a well-being champion, and an employee assistance programme should they need to. The provider had organisational values which were, ‘respect, integrity, passion, empathy and responsibility. These were discussed in staff supervisions and appraisals.
The provider had policies and procedures in place so they could support staff flexibly with their individual needs. This was through staff meetings, supervisions and when the need arose.
Governance, management and sustainability
The senior management team, registered manager and clinical lead for the service confirmed they undertook various quality assurance visits. Daily clinical meetings were being held with staff, these were an opportunity to discuss people’s individual care needs including any referrals needed for example to the GP/or other health and social care professionals or clinics.
The providers quality assurance systems were not always identifying shortfalls found during this inspection. For example, monthly care plan reviews had failed to identify where people’s care plans, risk assessments and mental capacity assessments were not up to date or accurate. The registered manager had an action plan that identified areas of improvement needed within the service. This included improvements to people’s mental capacity assessments, staff skills and knowledge around clinical complexities and improvements to some audits. The service was displaying the rating on the providers website.
Partnerships and communities
The service worked in partnership with professionals so that people received the care and support they needed. People were supported to participate in activities within the service and people had visitors when they chose. People spent time in their room or the communal area of the home. One relative told us the service had supported their loved one to attend the activities they were grateful of the support provided by the staff. People could go to the bistro area where various drinks and snacks were available for them and their visitors. The registered manager spoke about how they worked in partnership with the community and professionals. Various activities such as toddler groups, school visits, planned evening events were arranged for people and the registered manager also confirmed professionals were also welcome to use the facilities if they needed to.
The registered manager and clinical lead worked in partnership with other agencies so improvements could be made to people’s care and support. This included the GP, local authority, safeguarding team and other agencies that provided a multi-disciplinary approach.
Three health and social care professionals confirmed they had no concerns with the care provided to people. One professional told us, “I am happy with what I see.” Another health professional told us, “The home has worked well to improve consistent processes around prescribing, including swift registration of temporary and permanent residents, and maintained a good working relationship with our prescribing team.” They went on to say that the support provided to people was to a very high standard and that the management of the service gets excellent results for people regularly especially around the support they provide to people who were being supported with end of life care.
The registered manager attended provider meetings where they discussed the quality of the care and support provided. Regular meetings were being held with external professionals so people’s individual needs could be reviewed along with any referrals discussed.
Learning, improvement and innovation
The management of the service were open and transparent about the areas of improvement they wanted to make within the service. They confirmed they held regular meetings with staff around improvements they wanted to make along with any learning outcomes from complaints and incidents. They also told us they planned to participate in various projects that could improve people’s quality of life. The provider undertook a staff, resident and relatives survey these were an opportunity to gather feedback so improvements could be made. There was an action plan that identified different areas of improvement such as to the environment and the manager undertaking walk arounds. The service had various thank you cards on display in the main receptions area. They also collated all the compliments and saved these to the providers quality assurance system. Compliments included, ‘Thank you for all the care and support you have given’ and ‘Thank you to all at Beaufort Grange, we would like to say a massive thank you to all members of staff’. They went on to say, ‘The quality of the care (the person had) received has been outstanding’.
The provider had a complaints policy in place. Where people had raised complaints, compliments and concerns. These were logged along with any learning, outcomes and if any referrals or notifications had been made. One relative raised a complaint with us during our inspection. They felt able to raise this formally with the service. We raised this with the registered manager so they could liaise with the family also. People and relatives had their views sought through meetings and satisfaction surveys. The registered manager was also available to people and relatives should they need to raise any concerns with them.