CQC report explained · a nursing home
What the CQC found at Beechill Nursing 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
- There were enough staff and people received their medicines as prescribed. However, the home could not show that references had been obtained or followed up for the four recruitment files checked, creating an increased risk that staff suitability had not been fully assured.
- Effective?
- Good
- People were supported with eating, drinking, health needs and access to healthcare professionals. Capacity assessments were completed when people moved in, but reviews were not always completed when people's capacity later changed.
- Caring?
- Good
- People and relatives said staff were kind and respectful. Inspectors observed positive interactions and found that people's choices, privacy, cultural needs and independence were respected.
- Responsive?
- Good
- Care plans described people's individual needs and were regularly reviewed. Relatives were involved in care planning, complaints were responded to appropriately, and a new activities coordinator was developing activities in the home and community.
- Well-led?
- Requires improvement
- Relationships with local authority, commissioning and NHS teams had greatly improved, and a new electronic audit system was in use. However, staff file audits had failed to identify the recruitment problems found by inspectors.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind and responsive care, but unsafe recruitment checks and weaknesses in oversight remained.
The inspection was unannounced and took place on 12 and 13 July 2023. One inspector and an Expert by Experience spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home had enough staff, and people received their medicines, food and health support. Inspectors found the home clean, with suitable infection control. People and relatives described staff as kind, respectful and approachable.
The main safety problem was recruitment. None of the four staff files checked had references from previous employers, and there was no evidence that references had been chased. The home also needed to improve how it checked staff files and reviewed people's mental capacity.
The overall rating is Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective, Caring and Responsive were rated Good. This was the fifth consecutive inspection with an overall rating of Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's needs. People, relatives and staff agreed that staffing was sufficient, and agency use was low.
“There were enough staff on duty to meet people's needs.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed positive interactions and found that people's dignity, choices and independence were respected.
“People and relatives said the staff were kind and respectful.” from the report
Good health support
The home supported people with nutrition, fluids and access to health professionals. Referrals were made when needed, including to speech and language and podiatry services.
“People had access to a range of health care professionals, for example, speech and language team and podiatry, to help maintain their health and well-being.” from the report
Improved partnership working
The home had worked constructively with local authority and healthcare teams. Actions from joint visits had been completed or were in progress.
“There had been a vast improvement in relationships between the home, various local authority teams and commissioning.” from the report
Recruitment checks
seriousThe home could not evidence safe recruitment for the four staff files checked. References had not been obtained or chased, and one file did not include employment history.
“None of the 4 recruitment files checked had any references from previous employers.” from the report
Limited oversight of new staff
seriousWhere references were missing, the home used a generic risk assessment. It did not provide extra supervision or checks afterwards to confirm that staff were suitable to work with vulnerable people.
“No additional oversight through supervision meetings and spot checks were completed to assure the new staff member was suitable to work with vulnerable people.” from the report
Capacity reviews
needs fixingCapacity assessments were completed when people moved in, but were not regularly reviewed when people's ability to make decisions changed. CQC made a recommendation about this.
“However, if people's capacity changed after they had moved to Beechill, formal reviews of their capacity were not made.” from the report
Incomplete audit checks
needs fixingThe new electronic audit system was in use, but staff file audits had not identified the recruitment problems found during the inspection. CQC recommended that these audits be strengthened.
“However, the staff file audits had not highlighted the issues we identified in the safe domain.” from the report
- 01Have references now been obtained or properly chased for all staff, and how do you check staff suitability when a reference is unavailable?
- 02What extra supervision, spot checks or other safeguards are used for new staff before their recruitment checks are complete?
- 03How often are people's mental capacity assessments reviewed when their ability to make decisions changes?
- 04How are staff recruitment files now audited so that missing references and employment histories are identified?
- 05What progress has been made with the action plan requested by CQC, and what evidence can you show families?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the report also compares the current ratings with earlier focused and comprehensive inspections. This explanation was written from the published report of 16 August 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, December 2021
Rated Requires Improvement; inspectors found safe, kind care but weaknesses in management and checks.
This was an unannounced focused inspection on 30 November 2021. Three inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe and Caring. Inspectors found enough staff, safe recruitment, medicines given as prescribed, good infection control and respectful care. People and relatives were generally happy with the care.
The home was rated Requires Improvement for Well-led. Some audits were not detailed enough, and a 16-week gap in fire alarm and emergency lighting checks was not identified promptly. The manager had also refused Healthwatch access, and relationships with local professionals were strained.
The overall rating remained Requires Improvement. It had been rated Requires Improvement at the previous inspection and had held this rating for eight consecutive inspections. The home had to send CQC an action plan, and CQC said it would monitor progress and return.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs and saw that recruitment checks were carried out safely.
“There were enough staff on duty to meet people's needs. A relative said, "There's regular staff working” from the report
Good risk management
Risks were recorded clearly, and staff knew people and how to respond to known needs, including agitation and substance misuse.
“Risks were managed, and staff knew people well. Risk assessments, and guidance for staff to manage the known risks, were recorded on an electronic system.” from the report
Kind and respectful care
People and relatives were positive about staff. Inspectors observed positive interactions and found that people's choices, privacy and independence were respected.
“We observed positive interactions between people and members of care staff throughout the inspection.” from the report
Infection control
The home was clean, staff were observed using suitable protective equipment, and systems were in place for visitor testing and infection outbreaks.
“The home was visibly clean throughout. Cleaning schedules were used to ensure all areas of the home were cleaned.” from the report
Weak quality checks
seriousSome audits did not record what had been checked. This meant managers could not reliably identify problems, including the gap in fire safety checks.
“The lack of detail in some audits by the registered and general managers meant they were not always robust.” from the report
Fire safety checks were missed
seriousFire alarm, emergency lighting and fire door checks were not completed for 16 weeks. The checks had restarted by the inspection, but the gap was not identified by the home's audits.
“The fire alarm, emergency lighting system and fire doors had not been checked for a period of 16 weeks up to the 5 November 2021, before being re-started.” from the report
Poor partnership working
seriousThe registered manager refused Healthwatch representatives entry for an authorised visit. Inspectors also found strained relationships with the local authority and Clinical Commissioning Group.
“The refusal to allow Healthwatch representatives to carry out an enter and view visit was a breach of regulation 17 (2) (e) (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Training organisation
needs fixingTwo infection control training sessions and an infection control audit had been cancelled. The general manager said the home needed to organise staff time for training more effectively.
“We were aware that two further infection control training sessions, as well as an infection control audit had been cancelled.” from the report
- 01What changes have you made to ensure audits record exactly what was checked and what action is needed?
- 02How do you now make sure fire alarm, emergency lighting and fire door checks are completed on time?
- 03What has changed in your working relationship with the local authority, Clinical Commissioning Group and Healthwatch?
- 04How are infection control training sessions and audits scheduled and followed up?
- 05What are the current ratings and findings for Effective and Responsive, which were not inspected in this visit?
This was a focused inspection of Safe, Caring and Well-led only; Effective and Responsive were not inspected and their previous comprehensive inspection ratings carried over into the overall rating. This explanation was written from the published report of 24 December 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 Beechill Nursing Home
9 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021Requires improvementstayed Requires improvementSafe: GoodCaring: GoodWell-led: Requires improvement
- November 2020Requires improvementstayed Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2018Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- November 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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