CQC report explained · a nursing home
What the CQC found at Beacon House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Beacon House rated Requires Improvement; inspectors found risks to people's safety, consent and care records, with warning notices issued.
This was an unannounced inspection on 19 October 2023. Three inspectors and an Expert by Experience spoke with people, relatives and staff. They reviewed care records, medicines records, recruitment files and management checks.
Inspectors found important gaps in risk assessments and monitoring. These included missing choking assessments, incorrect pressure mattress settings, gaps in repositioning and food and fluid charts, and incomplete wound records. Some medicines guidance did not explain when different doses should be given.
The home had enough staff during the inspection, used safe recruitment processes and people said they felt safe. Staff knew people well, and relatives and staff spoke positively about the management. The overall rating changed from Good at the last inspection in 2017 to Requires Improvement. The provider must send an action plan and progress will be monitored.
People felt safe
People and relatives told inspectors they felt safe. Staff knew how to recognise abuse and how to report concerns.
“I am safe here, everything I need gets done.” from the report
Staffing and recruitment
Inspectors observed enough staff to meet people's needs in a timely way. Recruitment checks were in place, and staff were described as regular and familiar with people's needs.
“Safe recruitment practices were in place to ensure only staff suitable to work with vulnerable people were employed.” from the report
Training and healthcare
Staff had induction, ongoing training, supervision and appraisals. People could access healthcare professionals when needed.
“People had access to the healthcare services they required.” from the report
Environment and food
The home was well maintained, with communal areas, personalised rooms and an accessible garden. People gave positive feedback about the food.
“The home environment supported people's well-being. It was pleasantly decorated and well maintained.” from the report
Pressure-area and choking risks
seriousSome people did not have the required choking risk assessment. Repositioning records had large gaps, and eight pressure mattresses were set incorrectly for people's weights.
“Pressure mattress settings did not always match people's weights. We observed 8 mattresses that were not set correctly according to people's weights.” from the report
Food and fluid monitoring
seriousFood and fluid charts had significant gaps. Some people regularly did not meet their fluid targets, and there was not enough guidance about what staff should do.
“Records showed people regularly did not meet their target with some people having less than half the required target.” from the report
Consent and restrictive practices
seriousThe home did not always record the required legal decisions before using covert medicines or bedrails. This was a breach of the Mental Capacity Act requirements.
“A person had been receiving covert medicines. The covert procedure had been already implemented without a DoLS or best interests' decision prior to this being commenced.” from the report
Medicines guidance
needs fixingInstructions for as-needed medicines did not explain when to give different doses. Inspectors made a recommendation to update this practice.
“Where PRN protocols were in place there was no guidance regarding variable doses.” from the report
Weak quality checks
seriousAudits did not identify several problems with care records, pressure care, mattress settings and incident reporting. This was a breach of good governance.
“Quality checks and audits needed to be strengthened to ensure areas for improvement were identified and acted upon swiftly.” from the report
- 01What has been done to ensure every person with swallowing difficulties has a current choking risk assessment?
- 02How do you now check that pressure mattresses are set correctly and that repositioning is recorded for every person who needs it?
- 03What changes have been made to food and fluid monitoring, including what staff do when someone misses their target?
- 04How are covert medicines and bedrails now authorised and recorded under the Mental Capacity Act?
- 05What action has been taken in response to the warning notices, and how are audits now checking that improvements are sustained?
This inspection widened to cover Safe, Effective and Well-led after concerns about consent; Caring and Responsive were not inspected in this report, and the report says ratings for uninspected questions used the previous inspection ratings. This explanation was written from the published report of 23 November 2023 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, November 2020
Beacon House was inspected but not rated; inspectors found good infection prevention and control practice.
This was an announced inspection on 28 October 2020. It was part of a CQC thematic review of infection prevention and control in care homes during the coronavirus pandemic.
Inspectors found the home was clean and that cleaning, infection control audits and extra cleaning in busy areas were taking place. They were assured that the home was using PPE safely, testing people and staff, managing admissions and visits, and preparing for possible outbreaks.
The home was inspected but not rated. The inspection focused on infection prevention and control, rather than giving an overall quality rating.
Clean environment
The home was clean and airy. Extra cleaning was carried out in high-traffic areas several times a day.
“All areas in the home were thoroughly cleaned each day with some additional cleaning procedures for `high traffic areas` taking place several times a day.” from the report
Safe use of PPE
Staff were provided with PPE, and a PPE champion on each shift checked that it was being worn in line with national guidance.
“Staff we seen were wearing their PPE the correct way.” from the report
Managed visits
Family visits were booked in advance and could take place indoors or outdoors. The indoor visiting room had a transparent shield between visitors and residents.
“Visits from family members were booked in advanced and facilitated outdoors or indoors.” from the report
Safe admissions and testing
New admissions stayed in an isolation unit for 14 days before moving to their permanent room. People and staff were regularly tested, with plans in place for positive results.
“People and staff were regularly tested and contingency plans were in place in case any of the test results came back positive COVID-19.” from the report
Regular checks
The home completed infection control audits daily, weekly and monthly. Inspectors said these checks identified shortfalls and led to prompt action.
“Infection control audits were completed daily, weekly and monthly.” from the report
Inspectors raised no specific concerns in this report.
- 01Are the cleaning arrangements and infection control audits still carried out as described in the report?
- 02How are family visits arranged now, and what happens if an infection risk affects visiting?
- 03What isolation arrangements are used for new admissions?
- 04How often are residents and staff tested when there is an infection concern?
- 05What PPE checks and outbreak plans are currently in place?
This was an announced thematic review focused on infection prevention and control under the Safe question; the service was inspected but not rated overall. This explanation was written from the published report of 19 November 2020 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 Beacon House
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- November 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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88 live-in carers within about an hour of Bedford
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 76 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.