CQC report explained · a nursing home
What the CQC found at Beechcroft Nursing and Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some care plans did not contain enough detail about people's risks and needs, and some monitoring charts were incomplete. Inspectors also received mixed feedback about staffing levels and made recommendations for improvement.
- Effective?
- Good
- People's needs were assessed and care was delivered in line with current standards. People were supported with food and drink, healthcare, staff training and making choices.
- Caring?
- Good
- This question was not inspected during this focused inspection, so no new rating was given.
- Responsive?
- Good
- This question was not inspected during this focused inspection, so no new rating was given.
- Well-led?
- Good
- The provider had a management structure, audits and an improvement plan. Managers were working with staff to promote a more positive culture and improve engagement with people and relatives.
What inspectors found, November 2023
Beechcroft Nursing and Residential Home was rated Good overall, but inspectors found safety needed improvement.
This was an unannounced, focused inspection after concerns about the quality of care and management. Inspectors visited on 4, 12 and 18 October 2023, and spoke with people, relatives, staff and managers. They reviewed care records, medicines records, recruitment files and other records.
The home was rated Good overall. Effective and well-led were rated Good. Safe was rated Requires Improvement, as some care plans and risk monitoring charts were incomplete and feedback about staffing levels was mixed.
Inspectors found that medicines were stored and recorded safely, the home was clean, people were protected from abuse, and accidents were reviewed. They also found that people received effective care, support with food and drink, healthcare support and opportunities to make choices.
The home had been rated Good overall at the previous inspection, published in May 2023. The safe rating remained Requires Improvement. The inspectors made recommendations about care plans, risk monitoring charts and staffing levels, but the report does not record any breached regulations or enforcement action.
Clean and hygienic home
Inspectors found the home clean and hygienic. Staff completed regular cleaning tasks and used protective equipment appropriately.
“The home was observed to be clean and hygienic.” from the report
Medicines managed safely
Medicines were stored securely and administration records were accurate. The home also improved information for medicines prescribed only when needed during the inspection.
“People were supported to receive their medicines safely.” from the report
Effective care and support
People's needs were assessed and staff had relevant training, induction and supervision. People were supported to eat and drink enough and to access healthcare.
“People were supported to eat and drink enough to maintain a balanced diet.” from the report
Learning from incidents
Accidents and incidents were recorded, investigated and reviewed for patterns. The provider used this information to change practice where needed.
“The provider had systems in place to review and analyse accidents and incidents to look for patterns and trends.” from the report
Care plans and risk charts
needs fixingThree people's care plans lacked detail about some risks and needs. Monitoring charts for three people were not always completed as required, so staff unfamiliar with them might not have had all the information needed.
“Three people's care plans lacked detailed information regarding some aspects of their identified risks and needs.” from the report
Staffing and waiting times
needs fixingObservations showed enough staff to keep people safe, but people, relatives and staff gave mixed feedback. Some said people sometimes waited a long time or staff were too rushed to spend quality time with them.
“Some people and family members told us they sometimes had to wait a long period of time for support.” from the report
- 01What changes have been made to ensure every care plan gives enough detail about each person's risks and needs?
- 02How are risk monitoring charts for food and drink intake and skin condition checked for completeness?
- 03What has changed in staffing levels since the inspection, and how do you monitor waiting times for people's support?
- 04How do you make sure references are obtained correctly for every new member of staff?
- 05What improvements have been made through the electronic care planning system and the service improvement plan?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used when calculating the overall rating. This explanation was written from the published report of 2 November 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, May 2023
Rated Good overall; inspectors found kind, person-centred care, but the Safe rating Requires Improvement because some risk records were incomplete or inaccurate.
Inspectors visited without advance notice on 12 April 2023. They spoke with people living in the home, family members, staff and other professionals. They reviewed care plans, medicine records, staff files and other records.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. Inspectors found enough staff, safe medicines management, kind care, suitable activities and effective systems for responding to complaints and improving the service.
Safe was rated Requires Improvement. Some care plans did not contain enough accurate detail about risks, and food and drink charts and skin monitoring records were not always in place or completed fully. The provider knew about these issues and had started an action plan to address them.
Kind and respectful care
People and families spoke positively about staff. Inspectors observed positive relationships and found that people were treated with dignity.
“Staff treated people with kindness, respect and compassion.” from the report
Staffing and medicines
Inspectors saw enough staff on duty and people said requests for help were answered promptly. Medicines were given safely and at the right times.
“Medicines were managed safely by staff who had received training in medicines administration.” from the report
Personalised support
Care was based on people's wishes, preferences and usual routines. The home also offered activities and supported people to maintain important relationships.
“People received care that was person-centred and based on their wishes and preferences.” from the report
Checks and improvement planning
The provider's audits had identified the care-record problems, and a detailed action plan was being reviewed and updated.
“The provider had created a detailed action plan identifying areas in need of improvement.” from the report
Incomplete risk records
needs fixingSome care plans did not contain enough detail or accurate information about identified risks. This could make it harder for staff to follow the right support consistently.
“We identified some improvements needed to the level of detail and accuracy in some people's care plans.” from the report
No registered manager at inspection
minorThere was no registered manager in post when inspectors visited. A new manager had started but had not yet completed the registration application.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What changes have been made to make sure every care plan records risks in enough detail and remains accurate?
- 02How do you now check that food and drink charts are completed whenever they are needed?
- 03How are skin monitoring records checked for completeness, and what happens if a record is missing?
- 04Has the new manager completed their registration application, and who is responsible for management until this is resolved?
- 05How do you make sure staff are supported while the large number of service changes is being implemented?
This was an unannounced inspection of all five CQC key questions, with infection prevention and control also reviewed under Safe; it was the first inspection of this newly registered service. This explanation was written from the published report of 26 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.
Every inspection of Beechcroft Nursing and Residential Home
7 rated inspections over 9 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Beechcroft Nursing and Residential Home →
- May 2023GoodSafe: Requires improvementEffective: GoodWell-led: Good
Read what inspectors found at Beechcroft Nursing and Residential Home →
- January 2022Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2016Goodstayed GoodSafe: Requires improvement
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2022
Registered with the Care Quality Commission on 6 September 2022.
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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