CQC report explained · a residential care home
What the CQC found at Beacon House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found two medicines management problems, incomplete recruitment information and gaps in some care records. These were addressed during the visit, but the safe rating remained Requires Improvement.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. People told inspectors they were happy with their care and felt safely cared for by staff who knew them well.
- Responsive?
- Good
- This key question was not inspected during this visit. Inspectors noted that people were generally satisfied, although some said they sometimes had to wait for staff.
- Well-led?
- Requires improvement
- There had been three managers since January 2022, and audits had not identified issues found by an independent assessment. The new manager had started improvements, but they were not yet fully completed or embedded.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind care but medicines, records and management systems needed improvement.
Inspectors visited the home without warning on 24 and 25 July 2023. They spoke with people, a relative, staff, a health care professional and the manager. They reviewed care records, medicines records and records about safety and management.
People generally said they felt safe and were happy with their care. Staff knew people well, there were enough staff overall, and infection control, safeguarding and safety checks were in place. However, inspectors found two medicines problems, gaps in recruitment records and care records that did not always contain all the guidance staff needed. The manager dealt with these issues during the visit.
The home was rated Requires Improvement overall. Safe remained Requires Improvement, and Well-led changed from Good to Requires Improvement. The new manager had started an improvement plan, but inspectors said more time was needed to complete the work and show that the new systems were working consistently.
People felt safe
People generally said they were happy with their care and felt safe. They said staff knew them well.
“People told us they were happy with the care they received, they felt safely cared for by staff who knew them well.” from the report
Medicines were usually managed correctly
Apart from the two issues found, inspectors saw medicines stored securely and given as prescribed. Staff had medicines training and competency checks.
“All other medicines, including controlled drugs, were stored securely, in the correct place, at the correct temperatures.” from the report
Staff understood people's risks
Staff used the equipment people needed and understood their risks. Safety checks for the building, water, fire, gas and electricity had been completed.
“People's care was provided safely and people had any equipment they required.” from the report
The new manager had begun improvements
The manager had created an improvement plan, introduced trackers and started daily meetings to share important information.
“The manager had acted promptly in response to the report's findings and formulated a service improvement plan to address the areas identified.” from the report
Medicine storage and authorisation
seriousThickener was kept in two unlocked bedrooms, creating a possible choking risk if accessed by an unauthorised person. A cream had also been given from an existing supply before the prescription was obtained. Both issues were dealt with immediately.
“Two people had thickeners for their drinks which was stored in their unlocked bedrooms, this did not reflect national patient safety guidance.” from the report
Incomplete recruitment records
needs fixingSome staff files did not contain all the required information about previous health or social care roles. The manager had identified this and was seeking the missing information.
“The staff recruitment records we checked had references for staff's last 2 positions, but not all of their previous roles in health or social care as legally required.” from the report
Care plans did not contain all safety guidance
needs fixingSome risks were understood and managed in practice, but care plans did not always record important information, including falls risks, sensor mats and repositioning needs. The manager corrected these issues during the visit.
“Some aspects of people's care records required improvement, to ensure staff had written information as well as verbal guidance.” from the report
Management and audits lacked stability
needs fixingThere had been three managers since January 2022. Existing audits had not found several issues identified by an external assessment, and the new systems needed more time to become established.
“There had been 3 managers of the service since January 2022.” from the report
Some people waited for staff
needs fixingFive people said staff were sometimes busy and they had to wait after using their call bell. The manager had started a daily call bell audit to monitor response times.
“Five people said although their needs were met, staff were busy and on occasions they had to wait.” from the report
- 01What has changed since the inspection to make sure thickeners and all medicines are stored and given safely?
- 02Have all staff recruitment files been completed with the required previous employment information?
- 03How do you now check that care plans contain all falls, sensor mat and repositioning guidance?
- 04What results have the daily call bell audits shown, and how quickly are people being helped?
- 05How are the current manager and provider checking that the new quality audits identify problems and that improvements are completed?
This was an unannounced inspection focused on Safe and Well-led; the other key question ratings were not inspected during this visit and were carried forward from the previous inspection. This explanation was written from the published report of 24 August 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, April 2021
Beacon House was inspected but not rated; inspectors found strong infection control, with some health and safety risk assessments needing review.
This was an announced, targeted inspection on 5 March 2021. It looked at how well the home was prepared to prevent and control COVID-19 infections.
Inspectors found clear procedures for visitors, protective equipment, testing, cleaning and social distancing. People were supported to keep in touch with their families, including through phone and video calls.
Inspectors were somewhat assured that health and safety policies were up to date. Some risk assessments, including those covering fire safety, evacuation and staff from Black, Asian and ethnic minority backgrounds, had not been reviewed for the impact of COVID-19. The provider gave evidence after the inspection that these reviews had been completed.
The home was inspected but not rated. This means the visit did not provide a new overall quality rating.
Keeping families in touch
People were supported to contact family members by phone and video call. The home also allowed visits, with clear procedures for visitors.
“People had been supported to keep in touch with their families throughout the COVID-19 pandemic.” from the report
Infection control
Visitors were screened and given guidance and protective equipment. Inspectors found cleaning checks, infection control audits and robust procedures.
“We were assured that the provider was using PPE effectively and safely.” from the report
Compassionate support
The home adapted its procedures in a person-centred way. Inspectors heard examples of people being supported with compassion and understanding.
“People were supported in a person-centred way, when implementing the changes and procedures required to minimise the risk of COVID 19 in the home.” from the report
Health and safety reviews
needs fixingSome risk assessments had not been reviewed to consider the impact of COVID-19, including fire safety, evacuation and risks for some staff. The provider later confirmed that further assessments and policy reviews had been completed.
“Further risk assessments to manage all areas of Health and Safety within the home had not been reviewed to assess any COVID 19 impact, including fire safety and evacuation and risk assessments for Black, Asian and Ethnic Minority (BAME) staff .” from the report
- 01Can you show us the updated fire safety and evacuation risk assessments mentioned in the report?
- 02How do you check that health and safety risk assessments remain up to date?
- 03What infection control procedures must visitors follow now, and how are visits arranged?
- 04How are staff tested for COVID-19 and how do you respond to a positive result?
- 05How can residents keep in touch with family if an outside visit is not possible?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it did not provide new ratings for the wider service. This explanation was written from the published report of 13 April 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 Beacon House
5 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- August 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- August 2018Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- January 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- July 2017Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 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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