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

The service was not always well led. The registered manager did not have effective oversight of the quality of the service provided. Some records were not accurate or up to date. The audit process was not effective and opportunities to improve the service may have been missed. The service used an electronic records system. However, staff and management were not fully aware of how to use this system and inconsistencies identified at this assessment had not been picked up by audits. This led to a breach of regulation 17, Good governance, of the Health and Social Care Act 2008 (Regulated Activities) 2014.

This service scored 62 (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.

Staff felt well supported by management and felt confident to approach them with issues.

The registered manager carried out some audits. However, these were not completed consistently and actions identified were not always carried out. There were not robust governance and quality assurance systems in place to ensure that any opportunities to improve the service were identified and addressed in a timely manner. However, the service had begun to work with the local authority in addressing this issue. The service did not always accurately analyse data. Senior staff were not able to evidence effective oversight on their electric documentation system. For example, there was an error picked up by the inspection team which had not been picked up the management team. We were not assured that the service was acting upon the best information regarding risk. The service did not always have accurate, complete and contemporaneous records, with some records not being fit for purpose. For example, we identified there was a risk assessment required for a person who required support with their mobility. This was not present and could put the person and staff at risk.

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.

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