CQC report explained · a nursing home
What the CQC found at Beech Hill Grange
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2022
Beech Hill Grange was rated Good overall, with safe care but management checks needing improvement.
This was an unannounced, focused inspection on 11 May 2022. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe. Inspectors found enough trained staff, safe recruitment, suitable risk assessments and good infection control. They found that people received their medicines correctly, although checks of medicines records by managers were not always done consistently.
The home was rated Requires Improvement for Well-led. The main problem was inconsistent medicines auditing. Inspectors found no impact on people and the medicine records they checked were accurate. The overall Good rating used the previous ratings for the other areas, because this inspection did not assess them.
The inspection followed notification of a specific incident after which a person died. The report says the inspection did not examine the circumstances of that incident because it was subject to a criminal investigation. Inspectors found no evidence during this inspection that people were at risk of harm from that concern.
Enough trained staff
Inspectors found enough staff to meet people's needs. Staff had induction, training, supervision and checks of their skills.
“Our observations during the day, indicated there were enough staff on duty to support people with their care needs.” from the report
Good risk management
Risk assessments were detailed and regularly reviewed. Staff understood how to support people safely, including during emergencies.
“There were robust risk assessments in place to guide staff to how they should support people safely.” from the report
Safe medicines administration
Staff who gave medicines were trained and checked for competence. The records inspected showed medicines were administered correctly.
“Medicine Administration Records (MAR) noted all medicines were administered correctly and medicine count records accurately recorded the total of each medicine in stock.” from the report
Positive relationships
People, relatives and staff said management was approachable and that concerns were listened to. Staff promoted people's independence and choices.
“People, relatives and all staff we spoke with told us they felt listened to and the provider was approachable.” from the report
Infection control
Inspectors were assured that the home followed measures for preventing and managing infections, including use of protective equipment and support for visiting.
“We were assured that the provider was using Personal Protective Equipment (PPE) effectively and safely.” from the report
Inconsistent medicines audits
needs fixingSenior staff and managers had not completed medicines quality checks consistently. The records inspectors reviewed were accurate and there was no identified impact, but the home needed to make these checks regular.
“Medication audits were not conducted consistently. We found no impact; medication records we reviewed were accurate with no missing entries.” from the report
- 01How often are medicines audits now completed, and who checks that they have been done?
- 02Has the move from paper to electronic medicines records been completed, and what errors or inconsistencies has it identified?
- 03How are staffing levels reviewed when people's individual needs change?
- 04How will you show that the Requires Improvement rating for Well-led has been addressed?
- 05Which ratings for Effective, Caring and Responsive are currently carried over from the previous inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 16 June 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, March 2022
Beech Hill Grange: Inspected but not rated; inspectors found good infection control and clean premises.
This was an announced, targeted inspection on 22 February 2022. Inspectors checked infection prevention and control, and asked about staffing pressures linked to COVID-19.
Inspectors were assured that the home was managing infection risks. This included safe visiting arrangements, testing, use of protective equipment, admissions, cleaning and outbreak planning.
The home had enough protective equipment, which staff wore correctly. It was clean and free from odours. The home also had a process for checking staff vaccination status.
The service was inspected but not rated. This means the report does not give an overall Good, Requires improvement or Inadequate rating.
Protective equipment
The home had good supplies of protective equipment, and staff were using it correctly.
“The provider maintained good levels of personal protective equipment (PPE) and staff were wearing PPE correctly.” from the report
Visitor safety
Visitors and professionals had to follow safety steps, including testing, signing in and using protective equipment.
“There were safe measures in place for visitors, health professionals and other professionals who come to the service.” from the report
Clean environment
Inspectors found the home clean and without unpleasant smells. Some lounge tables had also been replaced with surfaces that were easier to clean.
“The service was clean and odour free.” from the report
Vaccination checks
The home had a clear process for checking staff vaccination status, including for newly recruited staff.
“There was a clear process in place to monitor staff vaccination status and the registered manager explained the process when recruiting new staff.” from the report
Inspectors raised no specific concerns in this report.
- 01What staffing pressures are you experiencing now, and how would these affect care for my relative?
- 02How do you check that new staff meet the current vaccination or exemption requirements?
- 03What arrangements are available if family members cannot visit the home in person?
- 04How do you identify and manage an infection outbreak?
- 05How often is your infection prevention and control policy reviewed?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 3 March 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 Beech Hill Grange
4 rated inspections over 7 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 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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