CQC report explained · a residential care home
What the CQC found at Brighton & Hove City Council - 83 Beaconsfield Villas
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, medicines, infection control, fire safety and safeguarding had improved. However, some risk assessments were out of date or lacked detail, and inspectors said there was an increased risk that people could be harmed.
- Effective?
- Good
- This area was not inspected during this focused visit. The report says the previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. The report says the previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. The report says the previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management systems, audits and communication had improved, but not all parts of the improvement plan had been completed and more time was needed for the changes to become established.
What inspectors found, July 2023
Brighton & Hove City Council - 83 Beaconsfield Villas is Requires Improvement; major improvements were found, and the home is no longer in Special Measures, but safety records and management checks still need work.
This was an announced focused inspection on 23 May 2023. Inspectors checked Safe and Well-led, spoke with relatives and staff, observed care, and reviewed care, medicine, recruitment and management records. People living at the home could not share their views directly.
The home had improved since its previous inadequate rating. Staffing, medicines, infection control, fire safety, safeguarding and support for people's choices had improved. Relatives and staff described better management, communication and support.
Some important work was not complete. Some risk assessments were out of date or lacked detail, and not all actions in the improvement plan had been completed. The overall rating and both inspected areas were Requires Improvement.
The home had previously been in Special Measures and had six breaches of regulations. Inspectors found enough improvement for it to leave Special Measures, and found no current breaches in the areas inspected. CQC will continue to monitor the home.
Improved staffing
There were enough staff to meet people's needs, including supporting them to go out and take part in activities. Staff had suitable training and recruitment checks were in place.
“Staffing levels had significantly improved and there were sufficient staff to meet people's needs effectively.” from the report
Safer medicines
Medicines were managed correctly, with regular audits and clear records for medicines given when needed. Staff competency was checked regularly.
“Medicines were now managed safely and correctly. Medicine audits were robust and being routinely completed.” from the report
Better safeguarding
The home had improved how it recorded and reviewed incidents. Staff understood how to recognise abuse and how to report concerns.
“This had improved and there were systems in place to track accidents and incidents, including evaluating any trends and patterns to minimise future risk” from the report
Kind, person-centred support
Inspectors saw staff treating people respectfully and supporting their preferences, communication needs and independence. Relatives and staff described a calmer and more positive atmosphere.
“There was a happy, relaxed and caring atmosphere at the service.” from the report
Risk records not always current
needs fixingSome risk assessments were out of date or did not contain enough detail. The home updated them after inspectors gave feedback, but this needs to be kept up to date.
“However, some risk assessments in people's care records were out of date or lacked detail.” from the report
Improvement plan not finished
needs fixingManagement checks had improved, but not every action had been completed. Inspectors said more time was needed for the changes to become firmly established.
“Not all elements on the plan had yet been implemented and further time was needed for this to embed.” from the report
Communication could be more consistent
minorRelatives said communication had improved, but one relative raised concerns about consistency because key workers were not present every day.
“The new keyworker scheme is good but they're not there every day, consistency is key.” from the report
- 01How do you make sure every person's risk assessment is reviewed promptly when their needs or risks change?
- 02Which actions from the current improvement plan are still outstanding, and when will each be completed?
- 03How have you maintained the improved staffing levels, and are there enough trained staff for people to go out and take part in activities?
- 04How will you provide consistent key worker contact and communication with relatives?
- 05What checks are now used to make sure incidents are recorded, reviewed and acted on?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 13 July 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, February 2023
Rated Inadequate and placed in special measures; inspectors found serious problems with staffing, safety and management.
The inspection took place on 27 and 28 October 2022. Two inspectors visited the home, an Expert by Experience contacted all six relatives, and the inspectors reviewed care and risk records, medicines, staff training, recruitment, maintenance and management information.
The home was rated Inadequate overall, and for Safe and Well-led. Inspectors found staffing shortages, gaps in specialist training, unsafe fire and building arrangements, weak infection control, poor medicines records and ineffective checks on risks and quality. They also found that people did not always receive person-centred support or enough help to go out and take part in activities.
The previous overall rating was Good, published in May 2019. This was a focused inspection of Safe and Well-led after concerns about staffing, risk management and governance. The other key question ratings were carried over from the previous inspection when calculating the overall rating.
Specialist behavioural support
The home had contact with a specialist behaviour support service about incidents involving distress, anxiety and high-risk situations.
“Managers and staff had regular contact with the local Behaviour Support Service which provided specialist review of incidents people experienced regarding distress, anxiety or when high risk and harm was experienced.” from the report
Family visits
Relatives were encouraged to visit, and people were supported to keep meaningful relationships with important people in their lives.
“People's relatives were encouraged to visit, and people were enabled to maintain active and meaningful relationships with people who were important in their lives.” from the report
Legal authorisations
The report says the home had sought or held the appropriate legal authorisations for deprivation of liberty, and conditions were being followed.
“Appropriate legal authorisations were sought or were in place to deprive people of their liberty within the DoLS framework.” from the report
Not enough staff
seriousStaffing levels were sometimes below what people needed to stay safe. This also reduced opportunities for walks, drives and other important activities.
“The service was sometimes not able to provide the staff ratio which people required to be safe.” from the report
Fire and building safety
seriousThere was no overall fire risk assessment, evacuation plans were unclear, and parts of the building needed repair. Inspectors also found damaged flooring, water leaks and black mould.
“There was no overall fire risk assessment in place to ensure all building fire risks and mitigations had been identified and robustly reviewed.” from the report
Risky restrictions
seriousStaff did not always follow agreed support plans when using restrictions or interventions. Inspectors found examples of unnecessary physical intervention and overuse of locked doors.
“Staff had not always followed people's agreed support plans when applying restrictions and interventions, such as overuse of locking doors and unnecessary physical intervention when responding to potential swallowing hazards.” from the report
Infection control
seriousInfection control was not regularly checked. Inspectors found areas needing thorough cleaning, out-of-date guidance and unsuitable storage of personal hygiene items.
“We were not assured that robust cleaning and infection control practices were in place.” from the report
Medicines management
seriousMedicine cupboards contained out-of-date and excess stock and were dirty. Records did not clearly show how people's symptoms were monitored before and after medicines given when needed.
“Medicine audits did not take place regularly to ensure medicine was properly stored and managed.” from the report
Weak leadership and checks
seriousManagement arrangements were inconsistent, audits were not effective, and known staffing and safety risks had not been dealt with promptly. Staff reported high stress and low confidence in consistent working.
“The provider had failed to ensure governance systems were effective in monitoring service quality, responding to poor quality and driving improvement.” from the report
- 01What staffing levels are now in place for each person, including when people need more than one-to-one support?
- 02What specialist training have permanent, new and agency staff completed, and how is their competence checked?
- 03What has been done to complete the fire risk assessment, improve evacuation plans and repair flooring, windows, leaks and mould?
- 04How are medicines now checked, stored and recorded, including medicines given only when needed?
- 05What changes have been made to management audits, staff supervision and the review of incidents and restrictive practices?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 21 February 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 Brighton & Hove City Council - 83 Beaconsfield Villas
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Brighton & Hove City Council - 83 Beaconsfield Villas →
- February 2023InadequateSafe: InadequateWell-led: Inadequate
Read what inspectors found at Brighton & Hove City Council - 83 Beaconsfield Villas →
- February 2022Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodstayed GoodSafe: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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Most charge £1,020 to £1,280 a week. 37 can care for a couple. 10 years' experience on average.
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