CQC report explained · a nursing home
What the CQC found at Southgate Beaumont
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People told inspectors they felt safe. Staffing, recruitment, risk management, medicines, infection control and accident reporting were found to be safe, although some people and relatives gave mixed views about staffing levels at different times.
- Effective?
- Good
- People had assessments and care plans, staff had suitable training, and people received support with food, drink and healthcare. The home was working within the Mental Capacity Act and had improved from the previous inspection.
- Caring?
- Requires improvement
- Some people said staff did not greet them, talk with them or respond well to call bells. Inspectors found instances where people were not treated with respect, so the home remained in breach of Regulation 10.
- Responsive?
- Good
- Care plans were personalised and updated when needs changed. Complaints were recorded and investigated, and people had access to activities, family visits and end of life planning, although some activity records were incomplete.
- Well-led?
- Requires improvement
- The home had audits, management checks and systems for gathering feedback. However, its governance arrangements had not fully ensured that people were always treated well, and the rating remained Requires Improvement.
What inspectors found, December 2019
Rated Requires Improvement; inspectors found safe, effective and responsive care, but some people were not treated with respect and leadership needed improvement.
This was an unannounced inspection carried out over three days. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They also checked care plans, risk assessments, medicines records, staff files and management records.
The home was rated Good for Safe, Effective and Responsive. Inspectors found people were protected from abuse, medicines were managed safely, staff were trained, healthcare was available and care was personalised. Activities and complaints handling were also seen as effective.
Caring and Well-led were both rated Requires Improvement. Some people and relatives said staff were not friendly, did not talk meaningfully with them or were rough when providing care. The home had quality checks, but these had not yet ensured that everyone was treated with dignity and respect.
The overall rating remained Requires Improvement. The home had improved since the previous inspection and met most of the earlier breaches, but Regulation 10 remained breached. CQC asked for an action plan and said it would return under its re-inspection programme.
People were kept safe
Inspectors found suitable staffing, safe recruitment, risk assessments, safeguarding procedures, infection control and accident reviews. Medicines were also managed safely.
“People were protected from the risk of abuse. People and their relatives told us they felt safe.” from the report
Skilled and supported staff
Staff completed induction and required training and received supervision and appraisal. Inspectors found staff had the knowledge and experience to meet people's needs.
“Staff received the training and support they needed to effectively meet people's needs.” from the report
Personalised care and activities
Care plans included people's health conditions, preferences and support needs. The home offered activities such as music, quizzes, arts and crafts and gentle exercise.
“People's care plans were person-centred and provided staff with guidance on how their needs should be met.” from the report
Improved complaints handling
Complaints were logged, investigated and answered. People and relatives knew how to complain and said they had confidence that concerns would be addressed.
“Complaints were logged, and records showed the registered manager investigated and responded appropriately when complaints were received” from the report
Inconsistent kindness and respect
seriousSome people and relatives said staff were not friendly, did not have meaningful conversations and could be rough. Inspectors found this was a continuing breach of the dignity and respect requirement.
“There were instances where people were not treated with respect.” from the report
Leadership had not fixed the culture fully
needs fixingThe home had audits and action plans, but its systems had not yet made sure people were always treated well. The Well-led rating therefore remained Requires Improvement.
“The provider's governance arrangements around ensuring that people were always well treated, had not yet made been fully embedded.” from the report
Some activity records were incomplete
needs fixingRecords for one-to-one activities did not always say what had happened or what attempts had been made to involve people. The manager said this would be corrected.
“We reviewed some plans however noted they were not completed appropriately as they did not detail what activities took place and what attempts were made to engage with people.” from the report
Some medicine information was missing from care plans
minorInformation was not always recorded for medicines given through a PEG tube and for some other medicines. The provider sent updated care plans after the inspection.
“However, information was not always available in people's care plans in relation to medicines to be given via Percutaneous Endoscopic Gastrostomy (PEG) tube” from the report
- 01What specific steps have been taken to ensure staff greet people, speak kindly and spend meaningful time with them?
- 02How do managers check that people are treated with dignity and respect during personal care and when they use the call bell?
- 03What did the provider's action plan say about the continuing Regulation 10 breach, and what evidence can you show that it has been resolved?
- 04How are one-to-one activities recorded now, including attempts to involve people who stay in their rooms or remain in bed?
- 05Have all care plans been updated with complete information for PEG medicines, anticoagulants and Diazepam?
This was an unannounced inspection covering all five CQC questions, with the inspection visit taking place from 10 to 15 October 2019. This explanation was written from the published report of 28 December 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.
What inspectors found, October 2018
Southgate Beaumont was rated Requires Improvement; inspectors found kind and organised care in some areas, but serious gaps in staffing, dignity, complaints and management.
This was an unannounced comprehensive inspection on 28 August and 6 September 2018. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They also checked care records, staff recruitment files, medicines, staffing records, complaints and management audits.
All five areas were rated Requires Improvement: Safe, Effective, Caring, Responsive and Well-led. The home had improved pressure ulcer care since the previous inspection, and inspectors found safe medicines systems, clean premises, individual care plans, trained staff, healthcare support and varied activities.
However, staffing levels were not always maintained and recruitment checks were incomplete. Call bells were sometimes answered very late, including one response taking more than three hours. Inspectors also found failures in dignity, mental capacity procedures, complaint handling, statutory notifications and management oversight.
The report says this was the first Requires Improvement rating for the home. Inspectors found seven breaches of legal requirements.
Improved pressure care
The home had addressed the previous breach about wounds and pressure ulcers. Inspectors found regular risk assessments, specialist referrals, wound records and appropriate equipment.
“At this inspection, we found improvements had been made which addressed the breach as the service was safely meeting people's pressure care needs.” from the report
Medicines and cleanliness
Medicines were securely stored, administered from original packaging and checked. The home was clean, and inspectors found suitable infection control arrangements.
“The service ensured the proper and safe use of medicines. It protected people from the risk of infection such as through keeping the premises clean.” from the report
Individual care and healthcare
People had assessments and care plans covering their health, personal care, communication and emotional needs. The home worked with community healthcare professionals and helped people access healthcare.
“People's records showed that a needs assessment was completed before they moved into the service.” from the report
Activities and relationships
People had access to activities seven days a week, and the home supported contact with relatives, friends and the wider community.
“The service provided people with a broad range of mental and physical stimulation.” from the report
Very late call bell responses
seriousCall bells were sometimes not answered within the home's six-minute standard. Some responses took over an hour, and one took over three hours.
“This showed one person's call at night was not responded to for over three hours, despite them elevating it to an emergency response.” from the report
Dignity and continence care
seriousInspectors found one person soaked in urine after refusing personal care. The care plan did not explain how staff should respond to refusals, and the provider's investigation identified shortfalls.
“incontinence management was not in keeping with the clinical standards expected of the team.” from the report
Mental capacity procedures
seriousRecords did not always show capacity assessments or best-interest decisions for people using bed rails. The home was also not consistently monitoring conditions attached to Deprivation of Liberty Safeguards.
“The above evidence demonstrates failures to ensure care and treatment was being provided in accordance with the MCA.” from the report
Complaints and oversight
needs fixingSome complaints were not recorded or answered properly, and there was no clear audit trail showing how complaints led to learning. Management audits had not identified the problems inspectors found.
“There was no audit trail to show what the complaint was, how it had been resolved, and what actions were being taken to ensure lessons were learnt.” from the report
- 01What staffing levels are now provided during the day, overnight and at the busiest times, and how are missed shifts covered?
- 02What has changed to make sure call bells are answered within six minutes, and how are delays investigated?
- 03How do you support someone who refuses personal care while protecting their dignity and continence needs?
- 04How do you record mental capacity assessments, best-interest decisions and any conditions attached to a person's Deprivation of Liberty Safeguards authorisation?
- 05How are complaints now recorded, answered and reviewed for learning?
This was an unannounced comprehensive inspection covering all five key questions, the premises and the care provided. This explanation was written from the published report of 16 October 2018 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Southgate Beaumont
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- December 2019Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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