CQC report explained · a nursing home
What the CQC found at Beech Haven
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were safe and protected from avoidable harm. Inspectors found safe medicines management, infection control and risk management, but identified shortfalls in recruitment records, staffing on some dates and repositioning records.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The home was managed by an experienced registered manager, with audits, a clear management structure and an open culture. The provider made immediate changes to improve auditing of repositioning records, but inspectors had not seen whether this was sustained.
What inspectors found, November 2022
Rated Good; inspectors found people were safe and the home was well managed, but recruitment, staffing and repositioning records needed improvement.
This was an unannounced focused inspection on 10 October 2022. Inspectors looked only at Safe and Well-led because of concerns about staffing and recruitment. They spoke with people, relatives, staff and healthcare professionals, and checked care records, medicines records, recruitment files and management records.
The home was rated Good for Safe and Good for Well-led. People were described as safe, medicines were managed properly, the home was clean, and staff understood safeguarding and risks. The management team used checks and audits to monitor the service and worked with healthcare professionals.
Inspectors found some recruitment records did not show that gaps in employment history had been investigated. Staffing levels were sometimes affected by sickness, and some repositioning records did not show that changes had happened as often as recommended. The provider acted immediately on these issues, but inspectors could not yet assess whether the improved repositioning checks would continue.
People felt safe
People and relatives told inspectors that the home felt safe and that staff were kind and supportive.
“People told us they felt safe living at Beech Haven and liked the staff who supported them.” from the report
Safe medicines
People received their medicines as prescribed. Staff were trained, their competence was checked, and administration records were accurate.
“We observed staff administering medicines to people in line with their prescriptions. There was accurate recording of the administration of medicines.” from the report
Clean and hygienic
Inspectors found the home clean and saw staff following infection prevention and control practices.
“The environment was clean, and staff were aware of Covid 19 enhanced cleaning procedures, such as deep cleaning and regular cleaning of high touch areas.” from the report
Good management oversight
The management team used audits and checks, involved people and relatives, and worked with healthcare professionals to support care.
“There was a process of continual improvement and quality assurance with a variety of audits such as medicines, care plans, call bells, health and safety checks.” from the report
Recruitment records
needs fixingSome recruitment files did not show that gaps in employment history had been investigated. The provider acted immediately and reviewed its process.
“Some records we saw had not evidenced investigation of gaps in employment history.” from the report
Staffing pressure
needs fixingPlanned staffing levels were not always met on some dates, mainly because of short-notice sickness. Inspectors saw enough staff on the inspection day, but staff said sickness could create pressure.
“Records of staff rotas showed some dates when planned staffing levels were not always met.” from the report
Repositioning records
seriousFor people at risk of pressure sores, records did not show that repositioning had always happened as often as recommended. The manager acted immediately, but the improvement had not yet been shown to last.
“Where people had been assessed as being at risk of developing pressure sores and required positional changes, records seen did not provide evidence that this was being achieved at the recommended frequency.” from the report
- 01How do you make sure there are enough staff when someone calls in sick at short notice?
- 02What changes have you made to recruitment checks, and how do you now record investigations into gaps in employment history?
- 03How are repositioning times recorded for people at risk of pressure sores?
- 04How often are repositioning records audited, and can you show that the improvements have been maintained?
- 05Which parts of the previous Good rating were not reviewed during this inspection?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection published on 10 September 2019. This explanation was written from the published report of 16 November 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, September 2019
Beech Haven is rated Good; inspectors found safe, kind and personalised care, with further end-of-life training being explored.
This was an unannounced inspection on 20 August 2019. Two inspectors spoke with six people living at the home, a relative, staff and visiting professionals. They also reviewed care plans, medicine records, staff files and management records.
The inspectors found that people were safe, received their medicines properly and had enough staff support. Care plans were current and reflected people's routines. Staff were described as kind, respectful and well trained. People were supported with food, healthcare, activities, communication and end-of-life wishes.
All five CQC areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found consistently good care at the time of the inspection. The previous inspection, published in March 2017, had also rated the home Good.
Safe staffing and medicines
Inspectors found enough staff to support people without rushing. Medicine administration, storage and records were checked and found to be safe.
“There were sufficient staffing to keep people safe.” from the report
Personalised care
Care plans reflected people's routines, preferences and communication needs. Staff used personal history and interests to tailor support.
“People's care plans were current and reflected people's personal preferred routines.” from the report
Kind and respectful staff
People spoke positively about staff, and inspectors saw care that respected dignity, privacy and independence.
“People complimented the staff that supported them and expressed general satisfaction with the service.” from the report
Activities and community links
People were offered activities such as reminiscence sessions, baking, pet therapy and outings. The home also had links with a local school.
“There were visits from the local school enjoyed by both, pupils and the people at the service.” from the report
Good management oversight
Staff understood their responsibilities and felt able to approach managers. Audits and staff feedback were used to improve the service.
“The quality assurance system used remained effective.” from the report
End-of-life training still being explored
minorNo one was receiving end-of-life support during the inspection. The management team was still exploring further training towards a recognised accreditation, so ask about its current position.
“The management team were exploring options of further training towards a nationally recognized accreditation in end of life care delivery.” from the report
- 01What progress has been made with the further end-of-life care training mentioned in the report?
- 02How will you assess and manage my relative's specific risks, such as falls or other health needs?
- 03How will you support my relative's preferred daily routine, communication needs and personal interests?
- 04What activities and outings are currently available, and how will you help my relative take part?
- 05How are medicine records and care plan reviews checked and followed up?
This inspection covered all five CQC key questions, and all five ratings remained Good from the previous inspection published on 30 March 2017. This explanation was written from the published report of 10 September 2019 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 Beech Haven
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Goodstayed GoodSafe: GoodWell-led: Good
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Inspected but not ratedSafe: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
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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