CQC report explained · a residential care home
What the CQC found at Beaufort House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, appropriate recruitment checks and effective management of individual and environmental risks. Medicines were administered safely and records checked showed no gaps.
- Effective?
- Good
- Staff were appropriately trained, supported and supervised. People received support with food, healthcare and their legal rights, including consent and decisions made under the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with dignity and respect and supported their choices, privacy and independence. Inspectors observed positive and supportive interactions.
- Responsive?
- Good
- Care plans were detailed, personalised and reviewed when needs changed. People were offered activities and choices, but some family members said communication was not always good enough.
- Well-led?
- Good
- Inspectors found clearer management, better organisation and effective audits. The provider sought feedback and acted on concerns, and the previous governance breach had been resolved.
What inspectors found, October 2018
Beaufort House was rated Good; inspectors found safe, kind and personalised care, with some family communication and end-of-life training issues.
This was an unannounced inspection on 17 August 2018. One inspector spoke with people, staff, managers, family members and professionals. They observed care and checked care plans, medicines, staffing, complaints, incidents and quality records.
The home supported five people, with space for six. Inspectors rated all five areas Good: Safe, Effective, Caring, Responsive and Well-led. They found enough staff, safe medicines arrangements, suitable risk assessments, trained staff and respectful relationships.
The home had improved since the August 2017 inspection, when it was rated Requires improvement and breached rules about staffing and good governance. At this inspection, those breaches had been addressed and the provider was no longer in breach.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and keep them safe. Medicines records were complete and arrangements for storage, ordering and checks were in place.
“People received their medicines at the right time and in the right way to meet their needs.” from the report
Skilled and supported staff
Staff had received relevant training, including training linked to people's specific needs. New staff had an induction and staff received supervision and appraisals.
“People's needs were met by staff who were competent, trained and supported appropriately in their role.” from the report
Kind, respectful care
Staff built positive relationships and respected people's privacy, dignity, choices and independence.
“Staff developed caring and positive relationships with people and were sensitive to their individual choices.” from the report
Personalised support
Care plans included people's histories, needs, communication preferences and guidance for staff. People were offered activities based on their interests.
“Care plans contained detailed information to enable staff to provide care and support in a personalised way.” from the report
Improved management
The home had improved since the previous inspection. Audits and action plans were being used to monitor quality and make changes.
“The provider was fully engaged in running the service and invited feedback from people, their families and professionals to help drive improvements.” from the report
Family communication
needs fixingSome family members said they were not always kept informed or included in decisions about ongoing care. The manager said this issue had been identified and was being addressed.
“I don't always feel that I am kept informed and I'm not always included in decisions.” from the report
End-of-life training
minorNo staff had received end-of-life care training at the time of the inspection. The manager was arranging advance care planning training with the local hospice.
“None of the staff had received training in end of life care, however, the registered manager told us that they were in the process of liaising with the local hospice to arrange 'Advance care planning training'” from the report
- 01How will you keep families informed about changes to a person's care and involve them in decisions?
- 02What progress has been made with advance care planning and end-of-life care training?
- 03How are staffing levels matched to each person's one-to-one support and changing needs?
- 04How often are care plans and risk assessments reviewed, and how are families involved?
- 05How are complaints recorded, investigated and used to improve the service?
This was an unannounced inspection covering all five CQC questions, including care for five people, staff records, care plans, medicines, complaints, incidents and quality monitoring. This explanation was written from the published report of 17 October 2018 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 2017
Rated Requires Improvement; inspectors found safe, caring support but weaknesses in staff training, family involvement and management.
This was the home's first inspection. It was unannounced and took place on 24 and 29 August 2017. Inspectors spoke with people living there, families, staff and a visiting professional. They also observed care and checked care plans, medicines, staff records, complaints and quality checks.
The home was rated Good for Safe and Caring. Inspectors found enough staff, suitable medicine systems, personalised risk assessments and respectful relationships. Staff understood people's communication styles and supported their choices and independence.
The home was rated Requires Improvement for Effective, Responsive and Well-led. Staff training and supervision were not consistent. Some planned activities did not happen, families did not feel listened to, records were incomplete and quality checks had failed to find these problems. The report identified two breaches of regulations.
Safety and risk support
People and families felt safe. Risks were assessed and staff understood how to reduce harm while supporting people's independence.
“Individual risks to people had been assessed and action had been taken to minimise the likelihood of harm.” from the report
Safe medicines
Inspectors found medicines were stored, administered and recorded safely. They found no gaps in the sample of medicine records checked.
“People received their medicines at the right time and in the right way to meet their needs.” from the report
Kind and respectful care
Staff built warm relationships with people, respected privacy and dignity, and responded patiently to different ways of communicating.
“Staff developed caring and positive relationships with people and treated them with dignity and respect.” from the report
Personalised care plans
Care plans included people's histories, preferences, communication styles and individual support needs. They were reviewed regularly.
“Everyone living at Beaufort House had a care plan in place which was centred on the person as an individual.” from the report
Staff training and supervision
seriousSome staff had not completed or updated required training. Supervision was inconsistent, so staff did not always have regular opportunities to discuss concerns and development.
“The provider had failed to ensure that staff were trained and competent for the role they were employed for.” from the report
Family involvement
needs fixingFamilies said they were not listened to or included enough in decisions about their relatives' care. Some meetings happened only after repeated requests or outside involvement.
“Family members did not feel involved or included in discussions about their relatives on going care.” from the report
Quality and care records
seriousAudits did not identify missing training, incomplete daily records or gaps in recording family and professional contact. Accidents and incidents were not always reviewed to prevent recurrence.
“There was not an effective system to monitor the quality of peoples' care records to identify omissions and to analyse concerns.” from the report
Healthy food choices
needs fixingSome people gained significant weight and records showed diets often included burgers, chips and takeaways. Inspectors found no evidence that healthier options had been offered or that decisions had been properly considered.
“There was no evidence that healthy options had been offered or encouraged.” from the report
Planned activities
needs fixingActivities such as swimming, bowling and walking were often replaced by less active options. Records did not always explain whether people had declined the planned activity.
“Activities were also in place which supported personal fitness, such as swimming, bowling and walking however these activities were frequently replaced with less active past-times” from the report
- 01What action has been taken to make sure all staff have completed and kept up to date with mandatory training?
- 02How often do staff now receive supervision, and how is this checked?
- 03How are families involved in care reviews and how are their concerns recorded and followed up?
- 04How do you record and review missed activities, accidents, incidents and near misses?
- 05How are healthier food choices offered and agreed for people who may not have capacity to make these decisions?
This was an unannounced first inspection that assessed all five CQC questions for a home registered in August 2016. This explanation was written from the published report of 14 October 2017 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 House
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- October 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016
Registered with the Care Quality Commission on 31 August 2016.
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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