CQC report explained · a nursing home
What the CQC found at The Beaufort Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2023
The Beaufort Care Home is rated Requires Improvement; inspectors found caring staff and better staffing, but continued risks with medicines, care records and management oversight.
This was an unannounced follow-up inspection on 19 June 2023. Inspectors spoke with people living at the home, relatives, a friend and staff. They reviewed care records, medicine records, training information, safety records, policies and recruitment files.
The overall rating improved from Inadequate to Requires Improvement. Safe, responsive and well-led were rated Requires Improvement. Effective and caring were rated Good. People said they felt safe, received their medicines on time, liked the food and were treated kindly.
Important problems remained. Some medicines, including prescribed creams, were not managed safely. Risk information and care records were incomplete or inaccurate. Quality checks had not found these problems. The provider remained in breach of Regulations 12 and 17. Immediate actions and further improvement plans were put in place.
Improved staffing
There were enough staff during the inspection, recruitment checks were completed safely and agency use had decreased.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 18” from the report
Kind and respectful care
People felt listened to and inspectors saw positive relationships. Staff supported privacy, dignity, independence and daily choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Effective support
Staff had completed relevant training and supported people with food, drink and access to health professionals.
“People told us and records confirmed they were supported to access a range of services in a timely way which supported them to remain healthy and well.” from the report
More activities
People had more opportunities to take part in activities, including crafts and a music quiz.
“We found significant improvements had been made in this area.” from the report
Medicine safety
seriousSome prescribed creams were applied to the wrong area. Other creams lacked prescription labels or opening dates, and risks from flammable ingredients had not been assessed.
“The administration of prescribed creams remained unsafe.” from the report
Incomplete risk information
seriousSome records did not explain how staff should respond to choking. Tube-care records were incomplete, and action was not taken promptly when a person's blood sugar was too high.
“This exposed people to the risk of avoidable harm.” from the report
Care records
seriousSome records did not contain accurate, current or personalised information. This could lead to unsafe or inconsistent care.
“Some care records we reviewed lacked personalised information.” from the report
Management checks
seriousAudits and checks had not identified the problems found by inspectors. Staff also did not always follow infection-control expectations, including rules about jewellery and nail extensions.
“Audits and checks to monitor the quality and safety of the service were not yet fully effective and had not identified the shortfalls we found.” from the report
- 01What checks now make sure prescribed creams are applied to the correct place, labelled properly and recorded with their opening dates?
- 02How are choking risks, tube-site cleaning and high blood sugar levels recorded and acted on now?
- 03Which care plans have been updated with each person's communication signs, preferences and care instructions?
- 04How often are medicines, care records and infection-control practice audited, and can we see the latest results?
- 05What progress has been made with the new manager's action plan, and how will you show that improvements are lasting?
This was an unannounced follow-up inspection after a previous Inadequate rating and looked at all five key questions, including infection prevention and control. This explanation was written from the published report of 18 August 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, January 2023
Rated Inadequate and placed in special measures; inspectors found serious problems with staffing, medicines, risk management and leadership.
This was an unannounced focused inspection on 12 December 2022. Two inspectors and a specialist nurse adviser spoke with people, relatives and staff. They observed care and checked care records, medicine records, staff recruitment files and quality checks.
Inspectors found that safety had deteriorated since the previous inspection. There were too few staff at times, unsafe medicines practices, gaps in risk assessments, poor infection control practice and inaccurate or incomplete care records. People did not always receive personalised care or enough support with activities and personal care.
The home was rated Inadequate overall. Safe and well-led were rated Inadequate, while responsive remained Requires Improvement. Effective and caring were not inspected during this visit, so the report used their previous ratings when calculating the overall rating.
Permanent staff knew people
Inspectors found that permanent staff knew the people they supported. People also spoke positively about them.
“Permanent staff knew the people they supported, and people spoke highly of them.” from the report
Visitors were supported
Relatives were able to visit when they chose, in line with guidance.
“Relatives confirmed they were able to visit their family members when they chose.” from the report
Complaints process
People and relatives knew how to complain. Records showed complaints were handled according to the provider's procedure.
“Records showed complaints had been managed in line with the provider's procedure.” from the report
End of life training
Staff had received training and said they felt confident supporting people at the end of their lives.
“Staff had received training and felt confident to care for people at the end of their lives.” from the report
Not enough staff
seriousStaffing levels were sometimes below the level the provider had assessed as necessary. This meant people could wait for help and staff had less time to provide individual support.
“A review of the staff rota confirmed staffing levels the day before our visit were lower than the provider had assessed were needed.” from the report
Unsafe medicines management
seriousInspectors found missing medicine records, medicines that were not always available and failures to complete checks needed for insulin and other medicines.
“Three people's Medicine Administration Records (MAR) contained missing signatures and 4 people's MAR's showed their prescribed medicine had not always been available.” from the report
Risks were not well managed
seriousSome risks were not assessed properly or staff did not follow care instructions. Inspectors found examples involving falls, wound care, creams and feeding tubes.
“Systems and processes were not sufficient to demonstrate risk was identified, assessed and well-managed.” from the report
Personal care was missed
seriousPeople did not always receive care that matched their preferences. Several records showed people had not been offered or helped with a bath or shower for more than six weeks.
“Six of the 8 records we reviewed indicated people had not been offered or assisted to have a bath or shower for over 6 weeks.” from the report
Weak oversight
seriousThe provider's audits and checks failed to identify repeated problems. Previous improvements had not been maintained, and records were not always accurate or complete.
“The provider's continued lack of oversight and failure to operate effective systems and processes to make and sustain improvements to benefit people placed people at risk.” from the report
- 01What staffing levels are now being provided on weekdays, weekends and nights, and how are they matched to each person's needs?
- 02How are insulin checks, medicine availability, missing MAR signatures and the application of prescribed creams being checked now?
- 03Which risk assessments and care plans have been corrected, and how do you check that staff follow them?
- 04How will you make sure people receive their preferred personal care and have regular opportunities to do things they enjoy?
- 05What action has been taken in response to the warning notices and the special measures process, and how will progress be shared with families?
This was a focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 20 January 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 The Beaufort Care Home
12 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2023Inadequatedown from Requires improvementSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- March 2022Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2021Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2016Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020
Registered with the Care Quality Commission on 13 May 2020.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Coventry
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“My mum would not eat, drink, bath nor sleep without her. In short, she was FAMILY and we loved her dearly”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.