CQC report explained · a nursing home
What the CQC found at Beachcroft House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some risk assessments and care plans lacked enough detail or contained inaccurate information. Some medicine records and 'when required' medicine protocols did not follow the home's policy.
- Effective?
- Good
- People's needs were assessed using recognised tools, staff had suitable training plans, and people were supported with food, weight monitoring and healthcare.
- Caring?
- Good
- People and relatives described staff as kind, respectful and supportive. Staff promoted privacy, dignity, personal choices and contact with relatives.
- Responsive?
- Good
- Care plans reflected people's needs, interests and preferences. Activities were adapted to provide individual support during lockdown, and complaints were addressed.
- Well-led?
- Good
- People and relatives described the home as well managed and communication with managers as excellent. However, the home's own checks had not identified some problems with risk assessments and medicines.
What inspectors found, May 2021
Rated Good overall; inspectors found kind, person-centred care, but safety checks and some medicines practices needed improvement.
This was the home's first comprehensive inspection since it registered. Inspectors visited on three dates, spoke with people, relatives, staff and health professionals, and reviewed care plans, medicine records, recruitment files and management records.
People and relatives were generally happy with the care. Inspectors found kind and respectful staff, personalised support, good activities during lockdown, clean premises and suitable support with food, healthcare and communication.
The overall rating was Good. However, Safe was rated Requires Improvement because some risk assessments were not detailed or accurate enough, and some medicine procedures did not follow the home's own policy. The other four areas were rated Good.
Kind and respectful care
People and relatives reported that staff were kind, patient and supportive. Inspectors also observed positive interactions.
“People and their relatives were happy with the quality of care and support they received at the service.” from the report
Clean and hygienic home
The home had cleaning systems, infection control audits and procedures for visitors and protective equipment. Inspectors found the premises clean and free from bad smells.
“The premises were clean, hygienic and free from any malodours.” from the report
Personalised support
Care plans included people's needs, interests, preferences and backgrounds. Staff provided individual activities during lockdown, including games, reading and memory quizzes.
“People had individualised plans of care which were developed using assessments of their needs and information about their interests and preferences.” from the report
Good family contact
Staff helped people keep in touch with relatives through calls, window visits and electronic devices. Relatives were also kept updated about their family members.
“Staff supported people to maintain contact with their loved ones through telephone calls and through using electronic devices that enabled people to simultaneously speak and see each other.” from the report
Responsive management
People and relatives knew how to complain and felt confident approaching managers. Informal concerns were recorded and resolved.
“These matters were dealt with in an open and supportive way and action was taken to satisfactorily resolve people's discontent.” from the report
Risk plans were not always detailed
needs fixingSome risk assessments and management plans were inaccurate or did not give staff enough specific guidance. Inspectors recommended stronger monitoring of these records.
“Some of the risk assessments and risk management plans we reviewed needed additional information to promote people's safety in a thorough and effective manner.” from the report
Medicine records and protocols
needs fixingSome handwritten medicine records were not countersigned, and three protocols for medicines given when required were missing at the time of inspection. These issues were addressed during or after the inspection.
“Staff did not always ensure that entries were countersigned when a medicine administration record (MAR) chart was handwritten, which was not in line with the provider's medicines policy.” from the report
Quality checks missed problems
needs fixingThe home's monitoring systems had not identified the weaknesses in some risk assessments and medicine management. Inspectors recommended a more robust checking system.
“We found specific issues in relation to the robustness of risk assessments and shortfalls with some aspects of medicine management which were not identified by the provider's own quality assurance checks.” from the report
Small mealtime oversights
minorDuring the inspection, people were not supported to wash their hands before eating, and salt and pepper were not offered on one suite.
“However, we observed that people were not supported to wash their hands before eating and were not offered salt and pepper on one of the suites.” from the report
- 01What has changed in the risk assessment system since the inspection, and how do you check that each person's plan is accurate and detailed?
- 02How do you make sure handwritten medicine records are countersigned and that all 'when required' medicines have clear protocols?
- 03How do you check that staff know how to use medicine fridge thermometers correctly?
- 04How are people's falls risks and prevention plans recorded and reviewed?
- 05How will you continue to support activities, family contact and residents' meetings as restrictions change?
This was the home's first comprehensive inspection and covered all five key questions; a separate targeted infection prevention and control inspection on 22 January 2021 had found the service safe. This explanation was written from the published report of 1 May 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2021
Beachcroft House was inspected but not rated; inspectors found good infection prevention and control arrangements during a targeted Covid-19 review.
This was an unannounced, targeted inspection on 22 January 2021. It looked at infection prevention and control because of coronavirus outbreaks in care homes.
Inspectors found plans to reduce Covid-19 risks. These included a separate isolation unit, safe visiting arrangements, testing, staff training, personal protective equipment and regular infection control audits.
The home was assured in all the infection control areas checked. These included admissions, visiting, use of protective equipment, testing, cleaning, social distancing and managing outbreaks.
The service was inspected but not rated. This was not a full inspection of the home, so the report does not give an overall quality rating.
Isolation arrangements
The home had a separate isolation unit and garden for people who might find isolating in their own room difficult or traumatic.
“The service had a separate isolation unit with access to a garden for people who would find it difficult or traumatic to self-isolate in their own room when they received a positive test result.” from the report
Safe visiting
There was a process for managing visits safely, and this was changed when risks and government guidance changed.
“There was a clear process in place to ensure all visits to the service were managed safely.” from the report
Protective equipment
The home maintained stocks of protective equipment, trained staff in infection control and checked how equipment was used.
“The provider had systems in place to ensure stocks of personal protective equipment (PPE) were maintained.” from the report
Testing and monitoring
The home took part in whole-service testing and reviewed its testing schedule with local health protection advice.
“The service was taking part in 'whole service' testing in line with current government guidance to protect all residents and staff.” from the report
Inspectors raised no specific concerns in this report.
- 01Are the separate isolation arrangements and garden still available for people who cannot safely or comfortably isolate in their room?
- 02How are visits currently managed, and how quickly do you change the visiting arrangements when guidance or risks change?
- 03How do you check that staff are using personal protective equipment correctly now?
- 04How often are residents and staff tested, and how is the testing schedule reviewed?
- 05How do you currently prevent and manage infection outbreaks?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the wider areas of care were not assessed. This explanation was written from the published report of 23 February 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Beachcroft House
Each visit the CQC has published, newest first, back to the day the home was registered.
- May 2021Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- September 2020
Registered with the Care Quality Commission on 17 September 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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