CQC report explained · a residential care home
What the CQC found at Beech Haven
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found kind, familiar care, but medicines, risk management and quality checks were not reliable.
This was an unannounced focused inspection on 9 March 2023. Inspectors spoke with people, staff and relatives, checked care and medicines records, reviewed staff files, and inspected the building and infection control arrangements.
The home was not always safe. Medicines records and storage checks had gaps. Some risks, including falls, diabetes and catheter care, were not properly assessed or reviewed. Infection control was not always followed, and some areas were unclean or in disrepair.
People were generally happy and said staff were kind and available. Staff knew people well, recruitment checks were completed, and people received food, drinks and health support. However, the home remained in breach of Regulations 12 and 17 because its systems did not reliably manage safety and quality.
The overall rating remained Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were not inspected during this visit, so the report does not reassess them.
Kind and familiar staff
People were generally happy and spoke positively about the care. Staff knew people well and felt supported by managers.
“People at the service were happy living there. Their needs were being met and they were able to make choices about their care.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. The home had a stable team and used internal bank staff for short-term cover.
“There were enough staff to keep people safe and meet their needs.” from the report
Safe recruitment
The home completed recruitment checks, including DBS checks, and gave new staff an induction.
“The provider had an effective recruitment process in place to recruit staff safely” from the report
Food and healthcare support
People's nutritional needs and preferences were recorded. Staff worked with healthcare professionals when people needed extra support.
“People were supported to have enough to eat and drink and maintain a balanced diet.” from the report
Medicines were not reliably managed
seriousSome medicine records were not signed or checked properly. There were gaps in 'when required' medicine instructions, controlled drug records and refrigerator temperature follow-up.
“This meant people may not have been receiving their medicines as prescribed.” from the report
Risks were not always assessed
seriousSome people did not have clear risk plans for conditions such as diabetes or catheter care. Repeated falls were not fully reviewed to guide safer support.
“Failure to assess and plan for risks was a breach of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008” from the report
Infection control shortfalls
needs fixingSome toilets lacked soap or toilet roll. PPE was not always disposed of correctly, and some areas were visibly unclean or in disrepair.
“Systems to prevent and control infection were not always effectively implemented.” from the report
Quality checks missed problems
seriousThe home's audits and monitoring systems did not identify important safety and infection control issues. This was a breach of Regulation 17.
“The provider had quality assurance systems in place, however these were not effective as they did not always identify where improvements were needed” from the report
Dementia-friendly design
minorThe building had some suitable features, but there were no signs on toilet doors or pictures on bedroom doors. The provider was asked to consider national guidance.
“The provider had not followed best practice guidance when creating dementia friendly environments.” from the report
Mental Capacity Act practice
needs fixingSome relatives had signed consent forms without evidence that they had legal authority to do so. The provider was asked to review how it applies the Mental Capacity Act.
“The provider was not always consistent in following the principles of the MCA.” from the report
- 01What action has been taken to make sure medicine records, controlled drug counts and 'when required' medicine protocols are accurate?
- 02How are risks for diabetes, catheter care and repeated falls now assessed, reviewed and shared with staff?
- 03What has been done to improve infection control, including soap supplies, PPE disposal, cleanliness and repairs?
- 04How do your current audits identify problems with medicines, infection control and risk assessments?
- 05How are you making the home more dementia friendly and checking that consent follows the Mental Capacity Act?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 10 May 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 2021
Requires Improvement overall; inspectors found kind, personalised care, but medicines and quality checks were not always safe or effective.
This was an unannounced inspection on 7 September 2021. Inspectors spoke with people using the home, a visitor, managers and care staff. They observed care, checked medicines and records, and reviewed infection control.
People were described as happy and well cared for. Staff knew people well, treated them kindly and supported their choices. People had access to activities, healthcare, food and contact with family and friends.
The main problems were medicines management and record keeping. Some medicines were not stored safely, and information about medicines given when needed was incomplete. Records about people's care, mental capacity and needs were not always clear.
The home was rated Requires Improvement overall. Safe and Well-led were rated Requires Improvement, while Effective, Caring and Responsive were rated Good. This was the first inspection since the service became a limited company, although it had previously been rated Good under the former provider.
Kind and respectful care
People said staff were kind and caring. Inspectors saw staff offering reassurance, respecting privacy and allowing people time to make choices.
“People told us they had good relationships with the staff and that they were kind and caring.” from the report
Staff know people well
Staff and managers understood people's individual needs and preferences. Staff said they felt supported and had suitable training.
“Staff and managers knew people well and were able to tell us about them and how they liked to be cared for.” from the report
Personalised support
Care plans reflected people's needs and preferences, and staff responded when needs changed by making appropriate referrals and reviewing care.
“People received personalised care which met their needs and preferences.” from the report
Activities and family contact
People could join daily activities and use electronic devices to contact relatives and friends. Visits also took place under COVID-19 safety arrangements.
“There was a programme of activities and entertainment, with daily group activities such as baking, quizzes, exercise, games and craft activities.” from the report
Medicines were not always safely managed
seriousThe controlled drugs cabinet did not meet legal requirements. Medicines needing refrigeration were kept in the main fridge, whose temperature was not checked, and instructions for medicines given when needed were incomplete.
“Medicines were not always safely managed. Not all medicines were safely secured, and some records were not appropriate.” from the report
Quality checks did not identify recurring problems
seriousThe report says medicines concerns had been raised at earlier inspections and during a local authority visit, but similar problems were still found. This led to a breach of good governance.
“Concerns about medicines management were highlighted at past inspections and during a local authority visit to the service in 2020.” from the report
Some records were unclear or missing
needs fixingRecords did not always clearly explain people's needs or mental capacity. This could make it harder to show that care was being planned and delivered correctly.
“Systems and processes had not always been operated to ensure records were not always in place.” from the report
Some events were not reported to CQC
needs fixingThe provider had not always notified CQC about events that needed reporting, including events that stopped the service and deaths. Managers said they understood this responsibility and would do so in future.
“The provider had not always notified CQC of notifiable events, for example events that stopped the service and deaths.” from the report
- 01What changes have you made to the controlled drugs cabinet and medicine storage since the inspection?
- 02How are fridge and medicines-room temperatures checked and recorded now?
- 03How do you make sure instructions for medicines given when needed are complete, authorised and reviewed?
- 04How are care records and mental-capacity information checked for accuracy and completeness?
- 05What action plan was sent to CQC, and what evidence can you show that the Regulation 12 and Regulation 17 breaches have been resolved?
This was an unannounced planned inspection covering all five CQC questions, including infection prevention and control, with a partial tour of the environment; it was the first inspection since the service became a limited company. This explanation was written from the published report of 6 October 2021 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
8 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- October 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Requires improvementup from InadequateSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015InadequateSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2021
Registered with the Care Quality Commission on 27 April 2021.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Ealing
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 77 can care for a couple. 11 years' experience on average.
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
“She has an unusual combination of kindness and firmness, is quite unflappable, physically strong, extremely savvy”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.