CQC report explained · a nursing home
What the CQC found at Beechfields Nursing Home Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2024
Beechfields Nursing Home Limited is rated Inadequate and is in special measures; inspectors found serious safety, dignity and management failures.
This was an unannounced focused inspection. Inspectors visited on 18 January 2024 and reviewed Safe and Well-led. They widened the inspection to include Caring after finding concerns about people's dignity. They spoke with people, relatives, staff and visiting professionals, and checked care records, medicines records and management documents.
Inspectors found people were at risk of harm. Safeguarding concerns were not always referred or investigated. Risk assessments were missing, medicines were not always managed safely, some environmental risks were not controlled, and staff did not have all the training needed for people's health conditions.
People were not always treated with dignity. Inspectors saw delayed personal care and a person eating without cutlery. However, people and relatives also described staff as kind, and people said they felt safe, involved in decisions and supported to make choices.
The overall rating fell from Requires Improvement to Inadequate. The home is in special measures. CQC required an action plan and imposed registration conditions requiring suitably qualified oversight of risk, safeguarding and governance.
People felt safe and supported
Despite the inspection findings, people said they were happy living at the home and felt supported by staff.
“I am happy here, I feel safe. The staff are smashing, they are very good.” from the report
People were involved in choices
People said staff listened to them, explained what they were doing and involved them in decisions about their care.
“I have choices. I choose what time to wake up and go to bed. I choose what I want to do. The staff help me.” from the report
Partnership working
The provider worked with health and social care professionals, including therapists and nurses, and relatives gave positive feedback about obtaining suitable equipment.
“They have worked really hard to get my relative the right equipment. They have worked really hard with the occupational therapist and physiotherapist.” from the report
Safeguarding failures
seriousIncidents involving abuse and distressed behaviour were not always investigated or referred to the local safeguarding team. This left people at risk of harm.
“The provider failed to submit safeguarding referrals to the local authority safeguarding team in accordance with their regulatory responsibility.” from the report
Incomplete risk management
seriousImportant risk assessments were missing for conditions and situations including epilepsy, diabetes, distressed behaviour and not having a call bell within reach.
“Risk assessments were not always in place to guide staff how to manage and mitigate risks to people.” from the report
Medicines were not always safe
seriousMedicine fridge temperatures were not managed correctly, pain relief patches were not checked daily, and one person's changed pain medicine did not have an administration protocol.
“Medicines were not always managed safely.” from the report
Dignity and personal care
needs fixingInspectors saw a person left undressed with personal care needs unmet, and another person eating without cutlery. The report says people were not always treated with dignity.
“People were not always treated with dignity.” from the report
Weak management oversight
seriousAudits did not consistently identify problems or record follow-up action. The provider had not learnt enough from the previous inspection, and governance remained in breach.
“The continued lack of oversight of the care and support provided placed people at risk of harm.” from the report
Environmental and infection risks
needs fixingWindow restrictors were missing, equipment was stored in communal areas, thickened drinks were left unattended, and infection control practices were not always safe.
“Environmental risks were not always managed safely which placed people at risk of harm.” from the report
- 01What specific changes have been made to investigate and report safeguarding incidents, including incidents involving distressed behaviour?
- 02How are risk assessments for diabetes, epilepsy, distressed behaviour and call bell access now checked and kept up to date?
- 03How are medicine fridge temperatures, pain relief patches and as-needed pain medicines now monitored?
- 04What training have staff completed on diabetes, epilepsy and responding safely to distressed behaviour?
- 05Who is providing the suitably qualified oversight required by the registration conditions, and how is their work recorded?
This was a focused inspection of Safe and Well-led, widened to include Caring; Effective and Responsive were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 4 September 2024 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 2020
Rated Requires Improvement; inspectors found kind and effective care, but medicines safety and management systems were not reliable enough.
This was an unannounced comprehensive inspection on 20 February 2020. Inspectors spoke with people, relatives, staff and a visiting professional. They observed care and reviewed care plans, medicines records, staff files and management records.
The home was rated Good for Effective and Caring. People were treated kindly, offered choices, supported with meals and helped to access health professionals. Staff were described as trained and knowledgeable, although more dementia training was suggested.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Inspectors found unsafe insulin equipment had been used, some blood sugar checks were missed, medicine records were incomplete and audit actions had not always been followed through. Complaints were not always handled within the home's own timescales.
The overall rating remained Requires Improvement, the same as at the previous inspection. Effective improved from Requires Improvement to Good, while Caring remained Good. The provider was asked to take action on medicines management and governance.
Kind and respectful care
Inspectors saw warm relationships between people and staff. Staff supported people with choices, privacy, dignity and independence.
“We saw positive interactions and staff showed us that they knew the interests, likes and dislikes of people.” from the report
Staff training
Staff had induction, regular training and supervision. Inspectors found staff had the skills and knowledge needed for people's care, although further dementia training was suggested.
“People told us, and staff confirmed they were trained for their role, and this helped them meet people's needs.” from the report
Meals and healthcare
People had a choice of food and received help with meals where needed. Records showed access to healthcare professionals when required.
“People enjoyed a choice of meals and were supported to access professional healthcare outside of the home” from the report
Safeguarding awareness
Staff understood what abuse might look like and knew how to report concerns. A concern identified during the inspection was reported promptly to the local safeguarding authority.
“Staff understood what actions to take to protect people from harm and said they would follow the local authorities safeguarding procedures.” from the report
Medicines safety
seriousOne person received insulin using equipment linked to a risk of incorrect dosing. Blood sugar checks, patch records, nurse competency checks and medicine fridge checks were not consistently managed.
“One person had received insulin that was administered unsafely as the equipment used had been subject to a National Health Service (NHS) improvement notice, due to a risk of mis dosing.” from the report
Weak oversight
seriousThe provider's audits identified problems but some actions were still outstanding months later. This meant risks were not always identified and dealt with promptly.
“The provider did not have a robust system to allow assessment and monitoring of all aspects of the service.” from the report
Complaints handling
needs fixingThe provider did not always follow its complaints procedure. Some responses were delayed, including information requested during an external complaint investigation.
“There was evidence indicative of the provider not following their own complaints procedure.” from the report
Activities for people in rooms
minorPeople who stayed in their rooms had less stimulation. Staff interaction was usually limited to mealtimes and personal care, although some music and activity support were provided.
“There was less stimulation for people who were more dependent and stayed in their room” from the report
- 01What specific changes have been made to insulin equipment, blood sugar checks, patch records and medicine fridge checks?
- 02How are nurses' medicine competencies checked now, and how often are those checks repeated?
- 03How do you make sure actions from medicine and other audits are completed and independently checked?
- 04How are complaints logged, acknowledged, updated and answered within the timescales in your complaints procedure?
- 05What regular activities are offered to people who spend most of their time in their rooms?
This was a full unannounced inspection covering all five key questions, prompted partly by concerns about the quality and competence of nursing care. This explanation was written from the published report of 27 May 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 Beechfields Nursing Home Limited
8 rated inspections over 9 years: the service has slipped, from Requires improvement to Inadequate.
- September 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Beechfields Nursing Home Limited →
- May 2020Requires improvementstayed Requires improvementSafe: Requires improvementCaring: GoodWell-led: Requires improvement
Read what inspectors found at Beechfields Nursing Home Limited →
- February 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2019
Registered with the Care Quality Commission on 2 May 2019.
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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