CQC report explained · a residential care home
What the CQC found at Beech Tree House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2020
Overall Requires Improvement and still in special measures; safe care was rated Inadequate, with serious gaps in safeguarding, medicines and risk management.
This was a focused inspection to check whether the home had acted on its previous improvement plan. The first visit was unannounced. Inspectors visited on 11 and 23 September 2020, spoke with people, relatives, staff and professionals, observed care, and reviewed care, medicine, recruitment and management records.
The home had improved in some areas. Staffing levels, cleanliness, communication with relatives and contact with family had improved. Relatives generally described the new manager as making a positive difference. However, inspectors found people were still at risk because safeguarding, risk assessments, medicines, infection control and management checks were not reliable.
The overall rating improved from Inadequate to Requires Improvement, but the home remained in special measures because Safe was still rated Inadequate. The other four areas were all rated Requires Improvement. The report says the provider remained in breach of four regulations.
More consistent staffing
Staffing levels had improved and were more closely matched to people's identified support hours. The home was also limiting agency use where possible.
“Staffing levels during the day had increased in line with people's identified support hours, which was reflected on staff rotas.” from the report
Positive relationships
Inspectors usually saw staff engaging positively with people. Relatives generally said staff were kind and that the new management had made a positive difference.
“Staff appear helpful and kind. Happy with attitude of staff and management” from the report
Family contact
During the pandemic, staff supported people to keep in touch with relatives through calls and video calls. Some relatives also joined activities remotely.
“Throughout the pandemic staff routinely supported people to maintain contact with their relatives through video calls and phone calls.” from the report
Access to healthcare
People were supported to use a range of healthcare services, including their GP, occupational therapy and speech and language therapy.
“Records showed people were supported to access a range of healthcare services such as their GP, occupational therapy and speech and language therapy.” from the report
Safeguarding and financial risks
seriousThe home did not have reliable systems to protect people from financial abuse or unsafe online activity. Inspectors also found that some incidents of harm had not been referred promptly.
“there was no system to safeguard a person from financial abuse in relation to online bank card transactions.” from the report
Unclear risk guidance
seriousRisk assessments were not always updated after incidents and did not clearly tell staff how to keep people safe. This included risks linked to eating non-food items, grass, choking and allergies.
“Risk assessments were not always comprehensive, up-to-date and did not clearly identify hazards and associated safe measures.” from the report
Medicines records
seriousMedicine records, stock checks and guidance for as-required medicines were not always accurate or complete. Inspectors said this could mean people did not receive the correct medicine or dose.
“We found stock levels of medicines were not always recorded accurately.” from the report
Infection control
seriousThe home did not consistently follow its extra cleaning procedures or complete coronavirus temperature records. Water safety checks also had gaps and Legionella bacteria had not been eliminated from two outlets.
“We found records relating to Coronavirus were not always completed.” from the report
Mental capacity decisions
seriousSome care records contradicted each other about people's ability to make decisions. The home did not always follow the proper best-interests process or show that restrictions had the right legal basis.
“The service failed to follow the best interest decision process to consider safe alternatives for the person to access their money.” from the report
Limited activities
needs fixingActivities for some people were described as limited and repetitive. The home had recruited an activities coordinator and was trying new activities.
“Daily notes we looked at for September 2020 showed activities for some people were quite limited and repetitive.” from the report
- 01What has been changed to protect people from financial abuse, unsafe online activity and harm from other people's behaviour?
- 02How are risk assessments updated after incidents, and how do you make sure every staff member follows the guidance?
- 03How do you check that medicines records, stock levels, doses and as-required medicine instructions are correct?
- 04What evidence can you show that infection control checks, cleaning records and water safety procedures are now completed consistently?
- 05How are Mental Capacity Act and best-interests decisions recorded, and how do you check that restrictions are legally authorised?
This was a focused inspection covering all five key questions to check progress after the previous inspection and action plan, including infection prevention and control measures. This explanation was written from the published report of 11 November 2020 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, January 2020
Rated Inadequate and placed in special measures; inspectors found serious failures affecting safety, care, dignity, staffing and management.
Inspectors made three unannounced visits on 14, 18 and 21 November 2019. They spoke with people, relatives and staff, and checked care records, medicine records, staff files and management records.
They found faeces and urine in bedrooms and en-suites, unsafe and poorly maintained parts of the building, poor medicine practice and too few staff. People were not always protected from abuse and did not consistently receive the one-to-one support they were funded for.
People had limited choice over food, meal times, activities and daily life. Inspectors also found that staff did not always treat people with dignity, care plans and reviews were not reliable, complaints were not handled properly, and leaders did not have effective oversight.
All five areas were rated Inadequate. The previous overall rating was Good, published on 24 October 2017. The home was placed in special measures, with CQC saying it would request an action plan and return to check for significant improvement.
Healthcare access
Records showed that people were supported to attend routine appointments and to receive help from relevant health professionals.
“Care records showed that people were supported to attend routine healthcare appointments with GPs, dentists, opticians, community behaviour support teams and learning disability and mental health specialists.” from the report
Recruitment checks
The home carried out checks intended to help identify unsuitable staff before employment.
“Checks included Disclosure and Barring Service (DBS) checks, written references, health declarations, and proof of identity and of address.” from the report
Some suitable activities
Although many activities were not meaningful or age appropriate, records showed that some activities matched people's interests.
“For example, music therapy and swimming. Records showed these had taken place.” from the report
End of life planning
Some people's religious wishes and funeral preferences had been recorded in their care plans.
“People's end of life wishes had been considered.” from the report
Poor cleanliness
seriousInspectors found faeces and urine on floors, walls and bedding. Staff did not always use protective equipment when cleaning body fluids.
“People were at risk of contracting infections due to poor hygiene.” from the report
Unsafe premises
seriousThe building had several hazards, including unsecured blind cords, broken equipment and fire extinguishers locked away without readily available keys.
“People were not protected from unsafe and poorly maintained premises.” from the report
Medicine failures
seriousMedicine was missed, records were inaccurate and staff did not always follow safe procedures. One person had not received a prescribed medicine 11 times in one month.
“We noted the person had not received the medicine 11 times in the month of November 2019.” from the report
Not enough staff
seriousPeople did not always receive the one-to-one support they were funded for. Activities were cancelled and staff were working very long hours.
“There was a lack of staff to fully meet people's needs.” from the report
Poor dignity and choice
seriousPeople had limited choice over meals, meal times and activities. Inspectors saw staff provide support without speaking to people and heard derogatory language.
“People were not routinely treated with dignity and respect.” from the report
- 01What has changed since the inspection to make sure people receive the one-to-one support set out in their care plans?
- 02How do you now prevent missed medicines and check that medicine records and stock levels are accurate?
- 03What repairs and cleaning improvements have been completed, including the fire extinguishers, fire doors, blind cords, mould and broken kitchen equipment?
- 04What training and competency checks must staff complete before supporting people with medicines, autism, communication and behaviour?
- 05How are relatives now involved in care reviews, complaints and decisions about meals, activities and independence?
This inspection looked at the care provided, the premises and all five key questions; it was prompted in part by safeguarding concerns about staff conduct and the environment. This explanation was written from the published report of 25 January 2020 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 Tree House
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- November 2020Requires improvementcurrent ratingup from InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2020Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- October 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- October 2016
Registered with the Care Quality Commission on 10 October 2016.
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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