CQC report explained · a residential care home
What the CQC found at Bescot Lodge Care 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
- Medicines were not always stored safely, and medicine stock records were not always accurate. Inspectors found enough staff, suitable recruitment checks, effective safeguarding systems and infection control measures in line with guidance.
- Effective?
- Good
- This key question was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management systems did not provide enough oversight of medicines. Audits failed to identify problems with storage, temperatures and stock records, although people, relatives and staff described a positive and open culture.
What inspectors found, November 2021
Bescot Lodge Care Home rated Requires Improvement; inspectors found caring support and enough staff, but medicines storage and management checks were not reliable.
This was an unannounced focused inspection on 16 September 2021. Inspectors looked only at whether the home was safe and well-led, after concerns about abuse, medicines and movement alarms. They spoke with people, relatives, staff and visiting professionals, and checked care, medicines, recruitment and management records.
People were generally described as safe and well supported. There were enough staff, recruitment checks were completed, safeguarding systems were understood, and infection control measures followed current guidance. Risk assessments were person-centred and accidents and incidents were reviewed.
However, medicines were not always stored safely. The medicines room was above the recommended temperature on 13 of the previous 15 days, sharps boxes were stored on the floor, a controlled drugs cabinet was not secured to the wall, and stock records were not always accurate. Management checks had failed to identify these problems, leading to a breach of Regulation 17.
The overall rating remains Requires Improvement, as it was at the previous inspection published in November 2019. This is the second consecutive inspection with that rating. The CQC will ask for an action plan, continue monitoring the home and return to check progress.
Enough staff
Inspectors found staff were available when people needed them. People and relatives said staffing levels met people's needs and helped keep them safe.
“People told us there was a sufficient number of staff to meet their needs and keep them safe.” from the report
Person-centred risk planning
Risks such as falls and choking were assessed and reviewed in ways that reflected individual needs. Staff could explain how to manage these risks.
“Individual risk assessments were regularly reviewed and met the specific needs of people to keep them safe.” from the report
Safeguarding systems
Staff had safeguarding and whistleblowing training and understood how to report concerns. Inspectors found no evidence to support the abuse information they had received.
“The provider had clear safeguarding and whistleblowing systems in which staff had received training and knew how to effectively use.” from the report
Positive atmosphere
People, relatives and staff were positive about the home and its management. Inspectors observed an open and inclusive culture.
“There was a positive culture in the home. People, relatives and staff were complimentary about the home and the management team.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infection, including use of protective equipment, testing and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines were not stored safely
seriousThe medicines room was too warm on 13 of the 15 days checked. Sharps boxes were on the floor, the controlled drugs cabinet was not secured to the wall, and medicine stocks did not always match the records.
“The lack of governance systems and oversight meant medicines were not always stored safely” from the report
Management checks missed problems
seriousMedicine audits and other quality checks had not identified the storage, temperature and stock-record issues. This led to a breach of the good governance regulation.
“Medicine audits failed to identify that medicine stock counts were not always consistent with records and the control drugs cabinet was not secured to the wall.” from the report
- 01What has been done to keep the medicines room within the recommended temperature range?
- 02How are medicine stock counts now checked against records, including when a person leaves the home?
- 03How are sharps boxes labelled, dated and stored safely?
- 04How has the controlled drugs cabinet been secured and how is this checked?
- 05What action plan was sent to the CQC, and what progress has been made since the inspection?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 10 November 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, November 2019
Bescot Lodge Care Home rated Requires Improvement; inspectors found kind, responsive care but weaknesses in medicines safety and quality checks.
This was an unannounced inspection on 30 September 2019. Inspectors spoke with people, relatives, staff, the manager and a health professional. They observed care and checked care, medicines, staff and management records.
People were generally treated with kindness and respect. Staff knew people well, supported their choices and met their health, communication and activity needs. There were enough safely recruited staff, and people were protected from abuse and infection risks.
The home was not always safe because medicines were not consistently stored correctly, some medicine records were incomplete and guidance was missing for some medicines. Some risk and care records also lacked enough detail.
The overall rating was Requires Improvement. Effective, caring and responsive care were rated Good. Safe and well-led were rated Requires Improvement.
Kind and respectful staff
People described staff as friendly and helpful. Inspectors saw staff protecting privacy, dignity and independence.
“People were supported by staff who treated people with respect and maintained their dignity.” from the report
Enough suitable staff
Inspectors found enough staff on each shift. Recruitment records showed the required checks had been completed.
“There were enough safely recruited staff to support people when they needed it.” from the report
Personalised support
Staff knew people's needs and preferences. Care plans included personal information, communication needs and support with activities.
“People received person centred care and support to meet their needs.” from the report
Health and daily support
People were supported with food, drink and health appointments. Staff worked with health professionals and followed their advice.
“People were supported to maintain their health and seek support from health professionals.” from the report
Medicines safety
seriousSome topical medicines were left unlocked in bedrooms. Stock records did not match the medicines held, some administration signatures were missing and guidance was absent for some as-needed medicines.
“Medicines were not consistently stored safely; medicine records were not always accurate and guidance was not in place for some medicines to be administered.” from the report
Incomplete risk and care records
needs fixingSome records did not clearly explain how to support people with particular risks or behaviours. The manager said more detailed behaviour care plans would be introduced.
“People's risk assessments and plans were not consistently documented.” from the report
Quality checks missed problems
needs fixingThe home's audits did not identify the medicine problems or gaps in care and capacity records. This limited assurance that improvements were being found and made.
“The quality checks on the service were not consistently identifying concerns and driving improvements.” from the report
- 01How are medicines now kept locked, and how do you check that stock records and administration records are accurate?
- 02What written guidance is now available for medicines prescribed to be given when needed?
- 03How are individual risks and behaviours recorded in each person's care plan?
- 04How do you record mental capacity assessments and best-interest decisions for specific choices?
- 05How do your current audits show that earlier problems have been fixed?
This inspection covered all five CQC questions and looked at both the care provided and the care home premises. This explanation was written from the published report of 15 November 2019 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 Bescot Lodge Care Home
2 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- November 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2018
Registered with the Care Quality Commission on 5 October 2018.
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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