CQC report explained · a nursing home
What the CQC found at Beechwood Specialist Services
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2021
Targeted inspection not rated; the previous overall rating remained Requires Improvement, although inspectors found better safety checks and good infection control.
This was an unannounced targeted inspection on 19 August 2021. Inspectors looked at risk management, infection control and governance. They spoke with people, relatives and staff, and checked care records, the environment, training information and quality records.
Inspectors found that staff used personal protective equipment properly and followed infection control practices. People and staff were tested regularly for COVID-19. Risk records were clear, accidents and incidents were recorded, and relevant concerns were reported to the local authority and CQC.
The manager had made improvements to safety and quality checks. Staff training in safely managing risks had improved. However, this was not a full inspection. Safe and Well-led were inspected but not rated, and the previous overall rating of Requires Improvement remained in place.
Infection control
Inspectors were assured that the home used PPE safely, carried out testing and had arrangements to prevent or manage infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Clear risk records
Risk management records guided staff in keeping people safe. Risk assessments were being updated more consistently after significant incidents.
“Records relating to the management of risk were clear and guided staff in their practice to keep people safe from avoidable harm.” from the report
Improved management checks
The manager had introduced more robust checks on safety and quality and was following an action plan for further improvements.
“The registered manager demonstrated a commitment to ensuring the service was safe and had worked hard to implement more robust checks on safety and quality.” from the report
Staff training
More staff had been trained to intervene safely when people were at risk of harm. Relatives told inspectors staff were well trained to support people with behaviours that challenge.
“We noted improvements to the number of staff trained to safely intervene when people were at risk of harm.” from the report
Community visits
The home recognised the importance of people visiting friends and relatives and supported access to the community.
“People had access to the community and the service recognised the importance of facilitating outward visits with friends and relatives.” from the report
Previous rating still Requires Improvement
needs fixingThe overall rating did not change because this inspection was targeted. A full inspection is still needed before the service can receive updated ratings across all areas.
“The overall rating for the service has not changed following this targeted inspection and remains requires improvement.” from the report
Not a full inspection
minorThe inspection only looked at specific parts of Safe and Well-led. Effective, Caring and Responsive were not assessed.
“Targeted inspections do not change the rating from the previous inspection.” from the report
- 01What actions from the Regulation 17 Warning Notice are still outstanding?
- 02When will the remaining action plan improvements be completed?
- 03How often are risk assessments updated after a significant incident?
- 04How many staff are currently trained to intervene safely when someone is at risk of harm?
- 05When is the next comprehensive inspection expected, and which areas will it reassess?
This was a targeted inspection of specific parts of Safe and Well-led, including risk management, infection control and governance; the other key questions were not assessed and the previous ratings carried over. This explanation was written from the published report of 11 September 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, October 2020
Beechwood Specialist Services is rated Requires Improvement; inspectors found safety and management weaknesses despite kind care and safe medicines.
This was a focused inspection on 25 August 2020. Two inspectors looked at the premises, care, activities, records, medicines, staffing and management systems. They spoke with people, relatives, staff and professionals, and checked documents.
The home was not always safe. Four of six fire doors checked did not close properly. Some staff did not use face masks or social distancing correctly. Risk reviews after incidents were not clearly recorded, and some staff lacked recent training to intervene safely when people were at risk of harm. The provider took action about the fire doors during and after the inspection.
The home was not well-led because checks did not reliably identify or correct safety problems. Records did not always show what had been done after incidents or whether important events had been reported to the CQC. Medicines, staffing, recruitment and cleanliness were found to be managed safely, and staff were kind and respectful.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. This was the third consecutive inspection with that overall rating. The Effective question was not inspected, and the report covered only Safe and Well-led for this visit.
Kind and individual care
Staff treated people with kindness and respect. Inspectors found that care was provided in an individualised way.
“Staff demonstrated kindness and respect in their interactions with people. It was clear they provided care in an individualised manner.” from the report
Medicines
Inspectors found that medicines were stored and recorded properly, and people received them as prescribed from competent staff.
“Medicines were managed safely and people received their medicines as prescribed by competent staff.” from the report
Staffing and recruitment
There were enough staff during the inspection, and recruitment records showed the required checks had been completed.
“There were enough staff to meet people's needs and staff attended to people promptly.” from the report
Clean environment
The building was noticeably clean. Cleaning schedules had been increased because of the additional COVID-19 risk.
“Some aspects of environmental safety had improved following the last inspection. For example, the building was noticeably clean.” from the report
Fire safety
seriousFour of six fire doors checked did not close properly. The home’s checking system had not identified this problem, which could have allowed a fire to spread.
“Four out of six fire doors checked did not close properly and would not have been effective in limiting the spread of a fire.” from the report
Infection control and staff training
seriousSome staff did not wear face masks correctly or maintain social distancing. Staff also lacked recent training to intervene safely when people were at risk of harm.
“Staff did not consistently adhere to the relevant guidance for the use of personal protective equipment (PPE).” from the report
Weak management checks
seriousThe home’s systems did not reliably monitor safety or quality. This meant problems could remain unnoticed and people were exposed to avoidable risk.
“The service did not have robust and effective systems in place to monitor, assess and improve the safety and quality of service being provided.” from the report
Incomplete incident records
needs fixingRecords did not always show that risk assessments had been reviewed after incidents or that all required actions had been completed. It was also unclear whether all significant events had been reported to the CQC.
“Records did not demonstrate how risk had been reviewed following incidents.” from the report
- 01How have you checked that all fire doors now close properly, and how often will these checks be repeated?
- 02What training have staff completed since the inspection to intervene safely when people are at risk of harm?
- 03How do you now check that staff follow PPE and social distancing guidance?
- 04How are risk assessments reviewed and recorded after accidents or significant incidents?
- 05How will you show that all significant events are identified and notified to the CQC when required?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected during this visit and the report says previous ratings for uninspected questions were used in calculating the overall rating. This explanation was written from the published report of 1 October 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 Beechwood Specialist Services
3 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- September 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
Read what inspectors found at Beechwood Specialist Services →
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Beechwood Specialist Services →
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017
Registered with the Care Quality Commission on 31 March 2017.
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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