CQC report explained · a nursing home
What the CQC found at Beaufort Hall Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe and inspectors found medicines, risk management and infection control were generally handled safely. Staffing had sometimes fallen below minimum numbers because of staff absence and agency shortages.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Inspectors did observe kind and person-centred interactions, but no fresh rating was given.
- Responsive?
- Good
- This key question was not inspected during this visit. Inspectors found people were consulted about their care, food and activities, but no fresh rating was given.
- Well-led?
- Good
- The home had systems to monitor incidents, safeguarding, care plans, training and quality. Inspectors found improvements since the last inspection, although some care plans had not been reviewed earlier in 2022 and the environment needed some improvement.
What inspectors found, May 2022
Beaufort Hall Nursing Home is rated Good; inspectors found safe, kind care, but staffing pressures and some dated areas remained.
This was an unannounced inspection on 26 April 2022. One inspector spoke with people, relatives, staff and a health professional. They observed care and checked care records, medicines, recruitment, training and quality checks.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that people felt safe, medicines were managed safely, infection control was good and staff treated people kindly. People were involved in decisions about their care, food and activities.
There had been occasions when staffing fell below the expected minimum because of staff sickness and agency shortages. The home was recruiting and using agency staff and extra hours to cover gaps. Some parts of the building were dated and needed refurbishment.
The previous rating was Requires Improvement, published in August 2020. The home had previously breached rules about recruitment checks and notifying the CQC about safeguarding concerns. Inspectors found enough improvement had been made and there were no current breaches. Only Safe and Well-led were inspected at this visit; the other ratings were carried forward.
People felt safe
People and relatives spoke positively about the care. People said staff were attentive and kind.
“People and relatives spoke positively about the care and support that was in place.” from the report
Medicines were managed safely
The electronic medicines system alerted staff when medicines were due and helped identify missed doses. Staff administering medicines had been assessed as competent.
“Medicines were ordered, stored, administered and disposed of safely.” from the report
Good infection control
Inspectors found the home clean and free from odour. Staff used appropriate protective equipment and visits were being managed in line with guidance.
“We observed good infection control measures were in place.” from the report
Improved management systems
The home had improved how it recorded and followed up accidents, incidents and safeguarding concerns. Care plan checks had also improved by April 2022.
“Robust governance arrangements were in place, which enabled the provider and the registered manager to monitor the service.” from the report
Staffing pressures
needs fixingStaffing fell below the minimum numbers on some occasions because staff were unwell and agencies could not always provide cover. The home was recruiting and introducing a tool to help match staffing to people's needs.
“Staffing had fallen below the minimum staffing numbers on occasions in the last couple of months due to staff being unwell.” from the report
Some areas needed refurbishment
minorInspectors found some parts of the home were dated. A storage area had flaking paint and a sluice area contained an old mattress and other items, although these issues were addressed or planned for improvement.
“During a tour of the home, some areas were dated and would benefit from refurbishment.” from the report
Not all staff knew about DoLS authorisations
needs fixingThe manager monitored legal authorisations and their conditions, but not all staff knew which people had an authorisation in place. The manager said this would be discussed during handovers.
“Not all staff were aware of who had an authorisation in place.” from the report
- 01How often have staffing levels fallen below the planned minimum since the inspection, and how are gaps covered now?
- 02How is the new staffing dependency tool being used to match staffing to people's needs?
- 03What refurbishment work has been completed in the dated areas of the home?
- 04How do you make sure every staff member knows about people's DoLS authorisations and any conditions?
- 05How are care plans, accidents, incidents and safeguarding concerns checked and kept up to date?
This was a focused inspection of Safe and Well-led, prompted by concerns about staffing, risk management, records and governance; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 12 May 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.
What inspectors found, August 2020
Rated Requires Improvement; inspectors found kind care and safe medicines, but recruitment checks and reporting of safeguarding concerns were not reliable.
Inspectors visited on 16 and 20 July 2020. They reviewed care records, medicine records, staff recruitment files and management records. They spoke with staff and observed care, but did not speak with residents or relatives because of COVID-19.
The home had enough staff, managed medicines safely, assessed risks and maintained a clean environment. Staff were observed treating people warmly and kindly, and appeared to know them well.
However, recruitment checks were incomplete. Some required references had not been obtained before staff started work. Four safeguarding concerns were reported to the local authority but not to CQC. The systems used to monitor the home had not picked up these problems.
This was a focused inspection of Safe and Well-led. Both were rated Requires Improvement, and the overall rating fell from Good at the previous inspection, published on 14 November 2018.
Kind interactions
Staff were observed speaking warmly and kindly. They appeared to know people well and treated them as individuals.
“We observed very positive staff behaviour in supporting people.” from the report
Enough staff
Staffing levels were based on people's assessed needs, with arrangements to provide cover if there were staffing shortfalls.
“There were enough staff employed on each shift to look after people according to their assessed needs.” from the report
Medicines
Inspectors found that medicines were ordered, stored, given and disposed of safely, with audits and stock checks in place.
“Medicines were ordered, stored, administered and disposed of safely.” from the report
Clean environment
The home was described as bright, clean and fresh-smelling. Extra infection control measures were in place during the COVID-19 pandemic.
“The service was bright and clean and smelt fresh.” from the report
Incomplete recruitment checks
seriousOne staff member had only one reference, obtained more than four weeks after starting. Another required reference had not been requested.
“Staff were not always recruited safely.” from the report
Safeguarding reports not sent to CQC
seriousFour safeguarding concerns had been reported to the local authority but not to CQC as required.
“We found four safeguarding concerns which had been notified to the local authority but not to CQC.” from the report
Weak monitoring systems
needs fixingThe home's checks did not identify the recruitment and reporting problems. Some audits, including kitchen cleaning audits, were not completed regularly.
“Systems in place had not identified the shortfall in references before employing new staff.” from the report
Manager not registered
needs fixingA manager was in post but was not registered with CQC at the time of the inspection.
“There was a manager in post but they were not registered with CQC.” from the report
- 01How do you now make sure two references are obtained and checked before every new member of staff starts?
- 02What has changed to ensure all safeguarding concerns are reported to CQC as well as the local authority?
- 03Have the incomplete recruitment checks and unregistered manager issue been resolved?
- 04How often are kitchen cleaning and other quality audits now completed, and who checks that actions are followed through?
- 05What action plan did you send to CQC, and what progress has been made since this inspection?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 12 August 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 Beaufort Hall Nursing Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 22 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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