CQC report explained · a residential care home
What the CQC found at The Beeches 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
- Inspectors found environmental, fire safety, infection control and medicine-record problems. They said some aspects of the service were not always safe and there was an increased risk that people could be harmed.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried forward from the last inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried forward from the last inspection, although inspectors observed kind and respectful staff and received positive feedback.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried forward from the last inspection.
- Well-led?
- Requires improvement
- Management and audit systems did not always identify problems with safety, cleaning, fire arrangements, infection control and care-record reviews. This was a breach of Regulation 17.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found kind care but concerns about fire safety, infection control and management checks.
This was an unannounced inspection on 30 June 2022. Two inspectors spoke with people living at the home, relatives and staff. They also reviewed care, medicine, recruitment and management records.
The home was caring and staff understood people's needs. People and relatives gave positive feedback. Staff supported people in line with the Mental Capacity Act and appropriate legal authorisations were in place where needed.
Inspectors found shortfalls in safety checks, fire safety, cleaning and medicine records. Management audits had not identified several of these problems. The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement.
The previous overall rating was Good, published in January 2018. The other three key-question ratings were not inspected during this visit and were carried forward from the previous inspection.
Kind and respectful staff
Inspectors saw staff treating people kindly and respectfully. People and relatives also gave positive feedback about the staff.
“Staff were observed being kind and caring and spoke about people in a very respectful way.” from the report
Support with decisions
The home was working within the Mental Capacity Act. Inspectors found appropriate legal authorisations where people were deprived of their liberty.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Safer recruitment
The required pre-employment checks were completed, including checks by the Disclosure and Barring Service.
“The required pre-employment checks to ensure staff's suitability to work in a care setting were in place.” from the report
Action taken during inspection
The provider responded to issues raised during and after the inspection and brought in additional management support.
“The provider was responsive to the things we found and discussed with them during and following the inspection.” from the report
Fire safety risks
seriousFire doors were being replaced, but risks from the work had not been properly assessed. Some doors were propped open during the day, and personal evacuation plans lacked important details.
“As a result, fire doors were being propped open in the day and then closed again at night.” from the report
Weak management checks
seriousAudits had not identified important problems. Cleaning records, bedroom audits, bedding and mattress checks, fire checks and care-record reviews were incomplete or ineffective.
“We found no evidence that people had been harmed however, systems in place to monitor and improve the quality of the service were not always effective.” from the report
Infection control and cleaning
needs fixingThe laundry needed a deep clean and contained clutter and debris. There were no red disposable bags for contaminated laundry, and daily cleaning records had not been completed since the end of May 2022.
“The laundry needed a deep clean and there was a lot of clutter and items stored in this area.” from the report
Medicine records
needs fixingSome medicine administration records had gaps. Inspectors also found that records did not fully explain when staff should give pain relief to someone unable to ask for it verbally.
“There were some gaps on the medicine administration records where staff had not followed the medicine procedure, and signed to say the medicines were given as prescribed.” from the report
Staffing pressure
needs fixingStaff said weekends were difficult because care staff also covered domestic and cooking duties. The provider was recruiting and using some regular agency staff.
“Staff told us that staffing levels at weekends were difficult because they were also covering domestic and cooking roles.” from the report
- 01What has been done to make sure fire doors and personal evacuation plans are now safe and up to date?
- 02How are cleaning schedules, bedroom checks, bedding checks and mattress checks now monitored?
- 03How do you check that infection-control records and outbreak information are complete?
- 04How do you make sure medicine administration records are signed correctly and pain-relief instructions are clear?
- 05What changes have been made to weekend staffing and the use of agency staff?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 31 August 2022 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, December 2020
The Beeches Care Home: Inspected but not rated; inspectors were assured about infection prevention and control.
This was an announced, targeted inspection on 10 November 2020. It was carried out after concerns were received about infection control and prevention.
Inspectors looked at how the home prevented and controlled infections. They were assured that visitors, people living at the home and staff were protected through measures including social distancing, shielding, PPE, testing, cleaning and safe admissions.
The home was inspected but not rated. This means the visit did not give an overall quality rating or full ratings for all five areas.
Infection control
Inspectors were assured that the home had measures to prevent visitors catching or spreading infections.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Digital records
A smartphone application allowed staff to update cleaning schedules, care plans and other records quickly, reducing the need for shared paper records.
“The service had developed a smart phone application to enable staff to instantly update cleaning schedules, care plans and other records.” from the report
Maintaining relationships
The home supported people to keep in touch with loved ones safely, including through socially distanced walks.
“One person was supported to have socially distanced walks in the park with a loved one who wore person protective equipment (PPE).” from the report
Staff cover
The provider offered incentives for staff to work extra shifts at short notice, so the home did not need agency staff.
“The provider offered incentives to staff who worked an extra shift at short notice.” from the report
Inspectors raised no specific concerns in this report.
- 01Has the planned visitor room near the entrance been created, and how is it being used?
- 02How are cleaning schedules, care plans and other records updated through the smartphone application?
- 03How do you make sure PPE is used safely and that people and staff can access testing?
- 04How do you maintain staffing levels when someone is absent or extra cover is needed?
- 05What checks do you make before admitting someone new to the home?
This was a targeted inspection of infection prevention and control under Safe; it did not provide ratings for the other four questions or an overall quality rating. This explanation was written from the published report of 12 December 2020 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 Beeches Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodstayed GoodSafe: GoodWell-led: Good
- June 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 21 October 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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