CQC report explained · a nursing home
What the CQC found at Beaumont Park Nursing and Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People generally felt safe and medicines, recruitment and infection control were mostly handled well. However, some risk assessments and safety checks were out of date or not recorded clearly, and inspectors recommended reviewing staffing so staff had time to engage with people.
- Effective?
- Requires improvement
- People could access food, drinks and healthcare, and staff generally supported choice and consent. However, staff training and supervision were not fully checked, and inspectors could not be assured that food and drink support matched people's needs.
- Caring?
- Requires improvement
- Inspectors saw some kind and compassionate care, and some people and relatives spoke positively about staff. However, people were not always treated with dignity, privacy, kindness or respect.
- Responsive?
- Requires improvement
- Complaints were responded to and end of life care was described positively. However, people's preferences, communication needs and interests were not consistently recorded or supported, and some people spent long periods without activities or interaction.
- Well-led?
- Requires improvement
- The new manager and senior team wanted to improve the home and worked with outside professionals. However, management changes, limited staff support, weak involvement of relatives and ineffective audits contributed to a negative culture and missed problems.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found concerns about dignity, personalised care, activities and management, although people were usually kept safe.
Inspectors visited without notice on 17, 23 and 25 May 2023. They spoke with people, relatives and staff, and checked care records, medicines, staff files and management records. The inspection began as a focused check of safety and leadership, but was widened to cover all five areas after concerns about dignity and personalised care.
People generally felt safe, medicines were mostly managed safely, the home was clean and staff worked with health professionals. However, inspectors found that people were sometimes left without conversation or activities, and were not always treated with kindness, dignity or respect.
Care plans did not always describe people's needs, preferences or communication methods. Staff training, supervision and checks were not fully effective. The home had a new manager and took some immediate action, but inspectors said improvements needed to be made and sustained.
The overall rating and all five area ratings are Requires Improvement. This means the home was not consistently meeting the standards expected, and there was an increased risk that people's needs would not always be met.
Medicines were mostly safe
Staff had medicines training and regular checks of their competence. The home also used audits to help check medicines were given correctly.
“Staff were trained to administer people's medicines and had their competency to do this assessed regularly.” from the report
Clean environment
Inspectors found the home clean and without unpleasant smells. Infection prevention arrangements were also judged to be in place.
“The service looked clean and was free of malodours.” from the report
Choice and consent
Staff asked people for consent and made best-interest decisions when people could not consent themselves. People were supported to make everyday choices.
“Staff asked people for consent before supporting them.” from the report
Some positive care
Inspectors saw staff speaking kindly to some people. Some relatives and people also described staff as friendly and supportive.
“We observed some staff speak kindly and compassionately to people when supporting them to eat and drink or with daily living tasks.” from the report
Dignity and respect
seriousPeople were sometimes rushed or treated without enough privacy and dignity. Inspectors also found poor handling of some personal belongings and heard staff expressing frustration where people could hear.
“We found no evidence people had been harmed. However, people were not consistently treated with dignity and respect or kindness and compassion.” from the report
Too little interaction and activity
needs fixingPeople sometimes spent extended periods alone without conversation or meaningful activities. Staff said they often did not have time to provide support beyond essential care.
“People went for extended periods of time without any conversation or interaction from the staff team.” from the report
Care plans were incomplete
seriousCare plans did not always explain people's preferences, changing needs or communication methods. Some known needs, including dementia or depression, did not have a care plan to guide staff.
“People did not always receive person-centred care.” from the report
Food and drink support
needs fixingInspectors could not be assured that kitchen staff had the right training for different dietary needs. Records did not always clearly state how much food or drink some people needed.
“We could not be assured staff had the training to support people to eat and drink in line with their needs.” from the report
Management checks missed problems
seriousAudits did not always identify issues with care plans, dignity, staff support and activities. Staff and relatives also described limited communication and support from management.
“Governance systems were not always effective in identifying where improvements to the quality of people's care could be improved.” from the report
- 01What has changed since the inspection to make sure people are treated with dignity and respect at mealtimes and during personal care?
- 02How do you now record and review each person's preferences, communication needs and changing health needs?
- 03What activities and social contact are available on days when the social pastime co-ordinator is not working?
- 04How do you check that staff and kitchen staff have the training and supervision needed to support people's dietary and care needs?
- 05What action plan has been put in place following the breaches of Regulations 9, 10 and 17, and how can relatives see evidence of progress?
The inspection began as a focused inspection of Safe and Well-led, then was widened to a fully comprehensive inspection covering all five key questions. This explanation was written from the published report of 15 June 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 people were safe and the home was well-led, with some improvements still needed in staffing time, records and medicines guidance.
This was an unannounced focused inspection on 4 and 11 October 2022. Inspectors looked at Safe and Well-led because of concerns about medicines and staffing, as well as infection control. They spoke with people, relatives and staff, and checked care, medicines, staffing and management records.
The home was rated Good for Safe and Good for Well-led. Inspectors found enough staff to meet people's essential needs, safe medicines support, good infection control and systems for learning from accidents. However, staff were often busy and had limited time for social contact.
Some risk assessments and medicines protocols needed more detail. Care plans also needed more information about people's likes, dislikes and preferences. The management team had started work on these areas during the inspection.
The previous overall rating was Requires Improvement, published in May 2022. This inspection changed the overall rating to Good. The ratings for the other key questions were carried forward from the earlier inspection because they were not looked at this time.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report possible abuse.
“People were safe living at the service and staff had training to recognise and report potential signs of abuse.” from the report
Essential care was provided promptly
Inspectors found that people's needs were met in a timely way and call bells were answered promptly, despite staff being busy.
“Whilst staff were busy, we observed that people's needs were met in a timely manner.” from the report
Medicines were administered safely
People received medicines on time and in their preferred way. Audits and stock checks were used to monitor medicines.
“People were supported safely with their medicines.” from the report
Positive management
The management team used audits, feedback and an improvement plan to identify and address problems. Inspectors said improvements since the previous inspection had been made and sustained.
“The management team completed audits to monitor the quality of the service and acted where improvements were identified.” from the report
Clean environment
Inspectors found the service clean and fresh, with infection prevention and control measures being followed.
“The service looked clean and smelled fresh.” from the report
Limited time for social contact
needs fixingStaff were busy and had little time to talk with people beyond essential care. People and relatives also gave mixed feedback about staffing levels and time spent socially engaging.
“However, staff were very busy and had little time to speak with people other than for support with essential interactions such as personal care.” from the report
Risk assessments needed more detail
needs fixingSome risk assessments were not sufficiently specific to the individual. The registered manager was reviewing and improving them.
“Some of the risk assessments would have benefitted from being more detailed and specific to the person it was meant for.” from the report
Medicines guidance needed updating
needs fixingSome instructions for medicines given when needed and covert medicines lacked enough detail for staff. The manager reviewed and updated these protocols after inspectors raised the issue.
“However, some protocols about 'as and when required' (PRN) medicines and covert medicines lacked specific detail to help guide staff.” from the report
Care plans missed personal preferences
minorCare plans were detailed overall but did not always include enough information about people's likes, dislikes and preferences. Reviews were already under way.
“People's care plans were detailed, however could have contained more information about people's likes, dislikes and preferences.” from the report
- 01How do you make sure people have enough time for conversation, activities and one-to-one contact when shifts are busy?
- 02Which risk assessments have been reviewed, and how are they made specific to each person?
- 03How have the protocols for as-needed and covert medicines been updated, and how do staff follow them?
- 04How do care plans record each person's likes, dislikes and preferences?
- 05How are staffing levels reviewed when agency staff are unfamiliar with people's needs?
This was a focused inspection of Safe and Well-led, with infection control also reviewed; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 26 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 Beaumont Park Nursing and Residential Home
8 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Beaumont Park Nursing and Residential Home →
- October 2022Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Beaumont Park Nursing and Residential Home →
- May 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 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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