CQC report explained · a residential care home
What the CQC found at Beeches
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicine records, risk assessments and some infection prevention arrangements were not reliable enough. Inspectors found safeguarding systems, staffing and recruitment were satisfactory.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify problems with medicines, cleaning or care records. Inspectors also found that some care plans did not give enough detail about people's goals and life skills.
What inspectors found, November 2023
Pegasus Care – Beeches was rated Requires Improvement; inspectors found medicines, risk records and quality checks were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 28 September 2023, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records. The inspection also included the supported living service linked to the home.
The home was not always safe. Medicine stock records did not always match what had been given, some medicines were not dated when opened, and some risks were not assessed or recorded in enough detail. Inspectors also found wear and tear that could affect infection prevention.
The home was open and caring in several ways. Staff knew people well, there were enough staff, and safeguarding procedures were followed. However, audits and other management checks had not found important problems. The overall rating changed from Good to Requires Improvement.
Staff knew people well
Staff understood people's needs and knew how to reassure them when they became upset, even where written guidance was incomplete.
“People were supported by staff who knew them well and understood their needs.” from the report
Safeguarding
Staff had safeguarding training and knew how to report concerns. Procedures had been followed when unexplained bruising was raised.
“Staff had training on how to recognise and report abuse and they knew how to apply it.” from the report
Enough suitable staff
Inspectors found enough suitable staff to meet people's needs in the home and supported living service.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
Open management culture
The management team was open to feedback and worked directly with people. People, relatives and staff said they could talk openly with the team.
“There was a positive and open culture at the service.” from the report
Medicine records
seriousMedicine stock balances did not always match the medicines given. Some creams and liquid medicines were not dated when opened, creating a risk they could be used after expiry.
“However, when we checked the stock balance of medicines these were not always accurate with what had been administered.” from the report
Risk assessments
seriousSome individual risks were not recorded clearly enough. Care plans did not always explain the equipment needed or how staff should respond to eating and drinking risks.
“Risks to people had not always been individually assessed and managed effectively.” from the report
Weak quality checks
seriousAudits did not identify medicine stock errors, rust in a microwave or gaps in care records. This meant management did not have reliable oversight of the service.
“The provider's systems did not always effectively monitor the quality of care provided to drive improvements.” from the report
Wear and tear
needs fixingSome areas of the home and supported living houses had worn or damaged surfaces. Inspectors were not fully assured that this supported infection prevention.
“We were not always assured the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01How do you now record and check the correct stock balance for each person's medicines?
- 02How do you make sure creams and liquid medicines are dated when they are opened and not used after expiry?
- 03How are individual risks, including eating and drinking risks and restricted areas, assessed and explained in each person's care plan?
- 04What changes have been made to audits so they identify medicine errors, cleaning problems and missing care-plan information?
- 05What progress has been made with the action plan requested by CQC, and what evidence can you show us?
This was a focused inspection of Safe and Well-led, prompted partly by concerns about unexplained bruising; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 17 November 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, April 2019
Rated Good in all five areas; inspectors found safe, kind and personalised care, with improved quality checks.
The unannounced inspection took place on 4 March 2019. Inspectors spoke with people using the home and supported living service, relatives and staff. They reviewed care records, medicines records, staff files, incident reports and quality checks.
The home provided personal and nursing care for eight people with learning disabilities. It also supported 15 people with personal care in supported living accommodation. Inspectors found people were safe, medicines were given correctly, staffing was sufficient and the home was clean.
People were supported by kind staff who knew them well. They were involved in choices about their care, food, activities and daily life. Inspectors found that care plans were personalised and that people were supported to be independent.
All five areas were rated Good. The report says the provider had improved its quality monitoring since the previous inspection, when these systems had not always been effective. End of life care was not assessed because nobody was receiving it at the time.
Safe and effective support
Inspectors found that people were protected from abuse and avoidable harm. Staff had the training and skills needed to support people's needs.
“People received safe and effective care. Staff received training and had the skills to support people with meeting their needs.” from the report
Choice and independence
People were involved in decisions about their daily lives, meals and activities. Staff supported them to do as much as possible for themselves.
“People were encouraged to make decisions and choices for themselves and were encouraged to be independent.” from the report
Kind and respectful care
Staff knew people well and understood their preferences. Inspectors saw warm interactions and found that people's privacy and dignity were respected.
“We saw kind and caring interactions between people and staff.” from the report
Improved quality checks
The provider had strengthened its systems for checking and improving the service since the previous inspection.
“At this inspection we found the provider had made the required improvements.” from the report
Inspectors raised no specific concerns in this report.
- 01The registered manager had recently left. Who is managing the home now, and has the new manager completed CQC registration?
- 02How are people's risks and care plans reviewed when their health or behaviour changes?
- 03How do you check that medicines are given correctly and that any problems are acted on?
- 04What activities and community opportunities are available for my relative, based on their interests and choices?
- 05End of life care was not assessed in this inspection. How would you plan and provide this support if my relative needed it?
This was an unannounced inspection of the care home and personal care and support in four supported living settings; supported living premises and end of life care were not assessed. This explanation was written from the published report of 17 April 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 Beeches
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2019Goodstayed GoodSafe: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 14 December 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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