CQC report explained · a residential care home
What the CQC found at Beechcroft House Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People had individual risk assessments and plans, enough staff, safe medicines support and infection control arrangements. However, the fire risk assessment was not completed by a competent person, and window restrictors needed checking.
- Effective?
- Good
- This area was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- The management team was viewed positively, but policies contained outdated information and audits did not consistently record problems or actions taken.
What inspectors found, May 2021
Beechcroft House Residential Home was rated Requires Improvement because fire safety and management checks were not consistently effective.
This was a focused inspection on 7 April 2021. Inspectors looked only at Safe and Well-led, after concerns about risk management and building safety. They spoke with relatives and staff, observed care, and checked care, medicines, recruitment, building and management records.
People were generally supported safely. There were enough staff, medicines were managed safely, and infection control arrangements were in place. Inspectors also found systems for reporting incidents and learning from them.
However, the fire risk assessment had not been completed by a suitably competent person. Some policies were out of date, and audits did not always show what action had been taken. Window restrictors also needed checking against current guidance.
The overall rating changed from Good to Requires Improvement. Safe changed from Good to Requires Improvement, while Well-led remained Requires Improvement. The other three areas were not inspected, so their previous ratings were carried forward.
Enough staff
Inspectors saw enough staff on duty, and relatives and staff said people did not have to wait for support.
“We saw there were enough staff on duty to meet people's needs.” from the report
Safe medicines
Medicines were stored safely, staff were trained, and records showed medicines were given as prescribed.
“When people had their medicines, we saw this was in line with how this was prescribed and accurate medicine administration records were completed by staff.” from the report
Risk planning
People's individual risks were assessed, with plans to reduce risks such as falls. Emergency evacuation plans were also in place.
“People had risks to their safety assessed and plans were put in place to manage those risks.” from the report
Positive views
Relatives said they were happy with the care and felt people were safe. Staff also described a supportive team.
“Relatives told us they were happy with the care people received.” from the report
Fire safety assessment
seriousThe fire risk assessment had not been completed by someone with the required skills and training. This meant inspectors could not be assured that fire risks had been properly assessed and controlled.
“A fire risk assessment had been completed, however, we found this had not been done by a competent person with the right skills and training.” from the report
Weak management checks
needs fixingSome audits and checks did not show when a problem had been found or what action had been taken. This limited the assurance that identified issues were being followed through.
“The governance arrangements in the home were not consistently effective in identifying areas for improvement or capturing when action had been taken.” from the report
Outdated policies
needs fixingThe medicines and recruitment policies contained incorrect or outdated information, even though they had been reviewed.
“The medicines and recruitment policies despite being reviewed contained incorrect or outdated information.” from the report
Window restrictors
needs fixingInspectors could not confirm that the window restrictors met current guidance. The provider was asked to consider the guidance and update them if needed.
“We checked the window restrictors and could not be assured these met the current guidelines.” from the report
- 01Has the new fire safety risk assessment been completed by a competent person, and what actions did it identify?
- 02Have the window restrictors been checked against current guidance, and were any changes needed?
- 03How do your audits now record problems, the action required and whether that action has been completed?
- 04Have the medicines and recruitment policies been corrected and brought up to date?
- 05How do you check that feedback about menus and other improvements has been acted on and recorded?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 21 May 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.
What inspectors found, February 2021
Inspected but not rated; inspectors were assured that infection prevention and control measures were safe.
The home provides personal care for up to 25 older people. Eight people were living there when inspectors visited.
This was an announced, targeted inspection on 2 February 2021. It checked infection prevention and control measures, including visiting arrangements, cleaning, protective equipment, testing and admissions.
Inspectors were assured that the home was preventing and managing infection risks. Visits were managed safely, relatives could keep in touch by phone or video, and the environment was clean. The home was inspected but not rated.
Safe visiting
Visitors had temperature checks and were given PPE. The home also used video and telephone calls when visits were restricted.
“Temperature checks of visitors were completed and Personal Protective Equipment (PPE) was supplied by the service to ensure people were protected from the risk of cross transmission.” from the report
Contact with relatives
The manager kept relatives updated about their family member's wellbeing when visiting was restricted.
“the registered manager kept in regular contact with relatives to ensure they had up to date information about their relative's wellbeing.” from the report
Clean environment
Inspectors found the environment well maintained and clean. Extra cleaning had been introduced to reduce the risk of infection spreading.
“The environment was well maintained and clean. Additional cleaning had been implemented to lower the risk of cross transmission.” from the report
Support for staff
Staff received support during periods of anxiety and were directed to external wellbeing services when needed.
“Staff were supported by the registered manager during periods of anxiety and staff had been signposted to external wellbeing services where needed.” from the report
Up-to-date policy
Inspectors found that the infection prevention and control policy was up to date.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Further development suggested
minorInspectors signposted the provider to resources to develop its infection prevention and control approach. The report does not describe this as a breach.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What changes did you make after being signposted to resources to develop your infection prevention and control approach?
- 02How are visitors currently checked and provided with PPE?
- 03How do residents keep in touch with relatives if visits are restricted?
- 04How often are shared areas cleaned, and what extra cleaning is used during an outbreak?
- 05How are staff supported if they become anxious, and what wellbeing services can they access?
This was a targeted inspection of infection prevention and control under the Safe question; it was inspected but not rated and did not provide an overall service rating. This explanation was written from the published report of 27 February 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 Beechcroft House Residential Home
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- May 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Beechcroft House Residential Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Beechcroft House Residential Home →
- August 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 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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