CQC report explained · a nursing home
What the CQC found at Beech Lodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people received medicines safely, staff understood care risks, recruitment checks were completed and infection control procedures were followed. They also found enough staff to respond to people when needed.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found effective quality checks, supportive management and good links with healthcare professionals and the local community. The home had plans for continued improvement and responded to complaints.
What inspectors found, December 2022
Beech Lodge Nursing Home is Rated Good; inspectors found safe medicines support, enough staff and effective management, with some learning needed after a fire alarm incident.
This was an unannounced, focused inspection on 16 and 17 November 2022. It was prompted by concerns about medicines management and staffing. Inspectors found no evidence that people were at risk from these concerns.
Inspectors spoke with eight people, two relatives, nine staff members and three visiting healthcare professionals. They reviewed care plans, medicines records, recruitment checks and quality monitoring documents. They also checked infection prevention and control.
The safe and well-led questions were both rated Good. The overall rating stayed Good, as the ratings for Effective, Caring and Responsive were carried over from the previous inspection in 2019 and were not reviewed during this visit.
Medicines support
Staff were trained and assessed as competent before giving medicines. Inspectors found that people received medicines as prescribed and at the right time.
“People received their medicines as prescribed and when directed.” from the report
Staff availability
Inspectors found staff were available to respond to people when needed. Recruitment checks were also completed.
“People were supported by staff who were available to respond to them when needed.” from the report
Infection control
Staff had infection control training, used protective equipment appropriately and carried out regular cleaning of communal areas and frequently touched surfaces.
“We were assured the provider was preventing visitors from catching and spreading infections.” from the report
Quality monitoring
The management team checked care plans, medicines and the physical environment. They used these checks to identify and make improvements.
“The provider had effective quality monitoring systems in place.” from the report
Fire alarm response
needs fixingDuring building work, the fire alarm was activated. Inspectors found that staff response needed improvement because the nominated fire marshal was not clearly identified. The home had bought a high-visibility tabard and was identifying further learning.
“The registered manager identified some improvements were needed in the way staff responded to the alarm including the lack of identification of the nominated fire marshal.” from the report
Weekend staffing
minorOne person said weekends were sometimes short of staff, although they also said there was always enough help. Ask how staffing levels are checked at weekends.
“Weekends are sometimes short, but there's always enough.” from the report
- 01How many staff are normally on duty at weekends, and how do you cover sickness or other staff pressures?
- 02What changes have you made to staff training and the fire alarm response since the inspection?
- 03Who is the nominated fire marshal on each shift, and how will residents and visitors know who that is?
- 04How do you check that medicines, including time-sensitive and 'when required' medicines, are given correctly?
- 05What were the results of the resident, relative and staff surveys mentioned in the report?
This was a focused inspection of Safe and Well-led, with infection control also checked; the Effective, Caring and Responsive ratings carried over from the previous inspection. This explanation was written from the published report of 7 December 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 Lodge Nursing Home was rated Good; inspectors found kind, personalised care, but raised concerns about staffing, food and mental capacity records.
This was an unannounced inspection on 28 and 29 August 2019. Inspectors spoke with people living at the home, relatives and staff. They reviewed care records, staff records, medicines and management information. They also observed care and looked around the home.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were generally described as safe and well cared for. Inspectors found kind staff, personalised support, safe medicines management and responsive managers.
The report also records some areas needing attention. Staffing was not always consistent, views about food were mixed, and mental capacity records did not always show clearly how decisions had been assessed. The inspectors made recommendations, but recorded no breaches of regulations.
Kind staff
People were treated with kindness and compassion, and inspectors observed positive interactions between staff and residents.
“People were treated with kindness and compassion. We observed positive interactions between people and staff.” from the report
Safe medicines
Medicines were stored securely and records showed they were given as prescribed.
“Medicines were managed safely, and people received their medicines in line with good practice guidance.” from the report
Personalised care
Staff knew people's preferences and routines. People were supported to make choices and take part in activities.
“Personalised care was promoted. Staff could tell us about people's likes, dislikes and personal routines.” from the report
Responsive management
Relatives praised the management team's willingness to listen and act on feedback.
“Relatives told us they had seen marked changes for the better since the new registered manager had introduced some changes.” from the report
Learning and improvement
The home used audits, incident reviews and professional support to improve care.
“There was an emphasis upon continuous learning and improving care.” from the report
Staffing consistency
needs fixingStaffing deployment did not always match people's needs consistently. Call bell response times varied from one to six minutes, and the manager agreed to review night staffing.
“Deployment of staffing to meet the needs of people who lived at the home was not always consistent.” from the report
Food quality
minorPeople and relatives gave mixed views about the food. Inspectors fed this back to the manager so action could be taken.
“Feedback about the quality of food was mixed and included, "The food is alright".” from the report
Mental capacity records
needs fixingRecords did not always explain clearly which decision was being assessed or when and how capacity had been considered. The provider agreed to review its processes.
“Assessments of mental capacity had been undertaken but these were not decision specific and did not always demonstrate when and how capacity had been assessed.” from the report
Privacy incident
minorOne relative said their family member's privacy had sometimes been compromised. The manager took immediate action to prevent this happening again.
“One family member told us there had been times when their family members privacy had been compromised.” from the report
- 01What staffing levels are now provided at night, and how do you check that staff are deployed consistently?
- 02How quickly should staff respond to routine call bells, and how do you monitor response times?
- 03What changes have been made to the quality, temperature and texture of meals since the inspection?
- 04How are mental capacity assessments now recorded for each specific decision?
- 05How do you protect residents' privacy and check that previous privacy concerns have not happened again?
This was an unannounced planned inspection covering all five CQC questions, including the care provided and the home premises. This explanation was written from the published report of 28 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 Lodge Nursing Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- December 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Goodstayed GoodSafe: GoodWell-led: Good
- March 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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