CQC report explained · a nursing home
What the CQC found at Beaufort Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Beaufort Grange was rated Requires Improvement; inspectors found kind care but risks in safe moving and handling, records and management checks.
Inspectors visited on 15 and 18 May 2023. They spoke with people, relatives and staff, observed care, and checked care plans, medicine records, incident forms and quality checks. The inspection was prompted partly by concerns about safe care and staffing.
People were generally supported by kind staff and most feedback was positive. However, one person was supported unsafely with their mobility. Care plans did not always give enough information about individual needs, and some medicine records needed improvement. There was also some feedback that people could wait at busy times.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. This was a fall from Good at the previous inspection, published on 13 September 2022. The report identified breaches about safe care and governance.
Kind staff
People generally described staff as kind, friendly and helpful. Most staff said they felt supported by colleagues.
“People felt supported by staff who they described as nice and friendly.” from the report
Medicine administration
Nursing staff gave medicines safely and records showed when medicines had been given. The report identified recording improvements rather than a general failure to administer medicines.
“People received their medicines safely from nursing staff.” from the report
Incident follow-up
Accidents and incidents were recorded when needed. Records showed that advice was sought, injuries were monitored and falls were reviewed to help prevent similar incidents.
“Records confirmed analysis was undertaken to prevent similar incidents from occurring again and actions were taken to make referrals if required.” from the report
Clean and accessible home
Inspectors found the home clean, with good lighting and wide corridors. People's rooms were personalised.
“The home was purpose built with good lighting, wide corridors with pictures placed on the walls.” from the report
Unsafe mobility support
seriousInspectors saw one person being supported unsafely and not in line with staff training. The member of staff received refresher training and extra support after this was identified.
“During our inspection we observed 1 instance where the person was supported unsafely.” from the report
Incomplete care information
needs fixingSome care plans did not explain clearly enough how staff should support people with catheter, infection, diabetes or equipment needs. The manager addressed several of these points by the second day.
“People's care plans did not always contain detailed support plans in how staff were to support someone with their catheter care, infection, and diabetes care.” from the report
Management checks
seriousThe home's checks had not found the problems with care plans, mobility support and medicine records before inspectors did. This was a breach of the governance regulation.
“Although the registered manager was responsive to our feedback shortfalls were not identified prior to our inspection.” from the report
Communication and waiting
needs fixingSome people and relatives reported that communication was lacking and that action was not always taken when issues were raised. Some feedback also suggested people could wait at busy times.
“Some feedback did suggest at certain times of the day it was busy with staff supporting other people.” from the report
- 01What changes have been made to make sure all staff support people safely with moving and handling?
- 02How are care plans now checked for detailed instructions about catheter care, infection, diabetes and equipment such as slings?
- 03How are topical creams and as-required medicines such as angina spray now recorded?
- 04What action has been taken in response to concerns about communication and issues not being followed up?
- 05How do daily staffing checks make sure people do not have to wait when staff are providing one-to-one support or taking breaks?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected and the overall rating used the previous inspection ratings for those areas. This explanation was written from the published report of 4 July 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, October 2022
Rated Good; inspectors found safe, kind care and stronger management, but some people experienced delays answering call bells.
This was an unannounced inspection on 13 September 2022. Inspectors spoke with people living in the home, relatives, staff and health and social care professionals. They observed medicines being given and equipment being used, and checked care records, recruitment, training and quality checks.
The home was rated Good overall, with Safe and Well-led both rated Good. Inspectors found enough staff, safe medicines systems, risk assessments and suitable infection control. People and relatives generally said staff were kind, responsive and provided safe care.
The inspection followed notification of an incident in which a person suffered a serious injury. CQC did not examine the circumstances of that incident during this inspection because it was still investigating. The overall rating stayed Good, while the Well-led rating improved from Requires Improvement at the previous inspection.
Safe staffing
Staffing was planned around occupancy and people's individual needs. Inspectors found enough staff and a nurse was always on duty.
“People were supported by sufficient staff.” from the report
Risk management
The home recorded risks such as falls, skin damage and health conditions. Staff used equipment, monitoring and one-to-one support where needed.
“People were kept safe because systems were in place in respect of ensuring people's safety.” from the report
Safe medicines
Medicines were securely stored, recorded, audited and checked. People could manage their own medicines when assessments showed this was safe.
“Medicines were safely managed. There were systems for ordering, administering, and monitoring medicines.” from the report
Open management
Inspectors found an approachable management team, regular meetings and systems for reviewing incidents, risks and quality.
“There was an open, transparent and positive culture and people, their relatives, staff and professionals told us the management team were approachable.” from the report
Call bell delays
needs fixingTwo people said they had sometimes waited around ten minutes for their call bells to be answered, especially at night. The manager reviewed this and reminded staff that call bells should be acknowledged within four minutes.
“Two people told us on occasions they had to wait ten minutes for their call bell to be answered especially at night.” from the report
Care records need updating
minorSome care planning documents were based on old COVID-19 guidance and one person had duplicate plans. The home said these would be addressed.
“Some of the care planning documentation that we viewed would benefit from being archived.” from the report
- 01How quickly are call bells answered now, including at night, and how is this checked?
- 02What action was taken after people reported waiting around ten minutes for help?
- 03What is the current position of the CQC investigation into the serious injury mentioned in the report?
- 04Have the outdated COVID-19 care documents and duplicate care plans now been archived or corrected?
- 05How will you make sure staffing levels continue to match residents' individual needs?
This was a focused inspection of Safe and Well-led; the Effective, Caring and Responsive ratings were not inspected and were carried over from the previous inspection. This explanation was written from the published report of 13 October 2022 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 Beaufort Grange
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022GoodSafe: GoodWell-led: Good
- September 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 15 July 2013.
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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