CQC report explained · a residential care home
What the CQC found at The Beeches (Seven Kings)
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were supported safely, with risks assessed and reviewed. Inspectors found enough staff, safe recruitment, trained staff for medicines and systems to prevent infection.
- Effective?
- Good
- Staff received induction, training, supervision and appraisals. People were supported with nutrition, hydration, consent, mental capacity and access to health professionals.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people's needs and preferences and supported them to make choices and remain independent.
- Responsive?
- Good
- Care plans were personalised and reviewed monthly. People were supported with activities, community links, relationships and raising complaints.
- Well-led?
- Good
- Inspectors found positive management, supportive staff relationships and regular quality audits. There was no registered manager, but the manager was applying to register.
What inspectors found, July 2018
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
The announced inspection took place on 12 June 2018. One inspector reviewed information held by CQC, spoke with people, staff, relatives and a visiting professional, observed care, and checked care records, staff records and quality checks.
The inspectors rated the home Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. They found enough suitable staff, safe medicines arrangements, clean premises, trained staff and support that respected people's choices and independence.
The home had improved since the June 2017 inspection. Earlier concerns about fire doors, emergency evacuation plans, hazardous materials, contaminated water risks and accident investigations had been addressed. There was no registered manager at the time, although the manager was applying to register.
Improvements since 2017
The home had addressed the safety issues identified at the previous inspection, including fire doors, evacuation plans, hazardous materials and drinking water risks.
“At this visit we saw the PEEPs had been reviewed and contained the support individuals would require evacuating the service safely in the event of an emergency.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and robust recruitment checks. Medicines records were complete and staff had been trained to administer medicines safely.
“We looked at all the current medicine administration records being used and found they had been completed accurately and there were no gaps in signatures.” from the report
Kind and respectful care
People and relatives described staff as kind and caring. Staff protected privacy, respected dignity and encouraged people to do things for themselves.
“People were treated with dignity and respect. We saw staff always knocked on people's bedroom doors before they went in thus protecting their dignity and privacy.” from the report
Personalised support and activities
Care plans included people's needs, abilities, likes and dislikes. Activities reflected people's interests, and people could choose whether to take part.
“We saw activities were organised according to people's choices, interests and needs.” from the report
Quality monitoring
The provider used audits, meetings and feedback from people, relatives, staff and professionals to monitor and improve the service.
“There were regular comprehensive audits carried out to monitor the quality of the service and to identify how the service could be improved.” from the report
Manager not yet registered
needs fixingThere was no registered manager when inspectors visited. The manager was applying to register and was waiting for an interview date.
“The service did not have a registered manager.” from the report
Assessment information could be fuller
minorOne assessment was comprehensive, but inspectors said it could include more information about people's spiritual needs.
“We looked at a recently completed assessment and found that although it was comprehensive, more information could be added such as people's spiritual needs to make it more holistic.” from the report
- 01Has the manager now completed the application to become registered with CQC, and what is the current position?
- 02How are a new resident's spiritual or religious needs assessed and recorded?
- 03How are fire doors, emergency evacuation plans and fire drills checked now?
- 04How are medicines records checked each day, and what happens if a missed signature or medicines error is found?
- 05How are residents involved in choosing their care plans, monthly reviews and activities?
This was an announced inspection covering the home, the care provided and all five CQC question areas, with ratings based on the inspection visit on 12 June 2018. This explanation was written from the published report of 14 July 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.
What inspectors found, July 2017
The Beeches (Seven Kings) is rated Requires Improvement; inspectors found kind, personalised care but health and safety and governance shortfalls.
This was an unannounced inspection on 1 June 2017. The inspector spoke with people living at the home, staff, the registered manager and relatives. They also checked care records, recruitment files, training records, health and safety records and the building.
The home provided enough staff, safe recruitment, trained staff and support with medicines. People said they felt safe, and inspectors found care records were detailed and personalised. Staff were kind, respectful and supported people's independence, activities, food choices and healthcare.
However, inspectors found important safety problems. Fire doors were not closing properly, evacuation plans did not contain enough information, some shower fittings could contaminate drinking water, hazardous substances were not locked away, and a knife was accessible. Some accidents were not fully investigated.
The home was rated Good for Effective, Caring and Responsive. It was rated Requires Improvement for Safe and Well-led, making the overall rating Requires Improvement. The provider was in breach of two regulations and was required to send the CQC an action plan.
Personalised care
Care records included people's needs, preferences and routines. People and relatives were involved in planning and reviewing care.
“The care records were reviewed regularly to ensure they reflected the person's needs and information was updated to reflect changes that had taken place” from the report
Kind and respectful staff
People said staff treated them well. Inspectors saw staff listening, checking on people and supporting privacy and independence.
“During our visit, we saw staff treated people well and took time to listen to what they had to say.” from the report
Medicines support
Staff were trained to administer medicines and records showed people received them as prescribed.
“We saw staff administered medicines to people in a careful manner and checked they had taken them.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs and saw that recruitment checks were completed before staff started work.
“People were supported by sufficient numbers of staff to meet their needs. Staff had been recruited safely.” from the report
Activities and choice
People had a range of activities and were supported to choose food, activities and aspects of their daily lives.
“People were provided with a wide range of activities.” from the report
Fire safety
seriousFire doors were not closing properly. One bedroom door did not close, another was wedged open, and the laundry room door was held open with a fire extinguisher.
“We noted during our visit that none of the fire doors were closing properly against the frames.” from the report
Drinking water risk
seriousShower heads in five shower rooms could drop below the water level. Inspectors said this could allow contamination of drinking water.
“This could create a backflow (an unwanted flow of water in the reverse direction) and could be a serious health risk for the contamination of drinking water” from the report
Unsafe storage
seriousHazardous substances were not locked away, and a kitchen knife was accessible despite the known risk it posed.
“We also found COSHH (Control of Substances Hazardous to Health) materials were not being kept locked.” from the report
Incomplete safety checks
needs fixingHealth and safety checks were not completed properly and did not identify all the hazards found by inspectors.
“Two records were half completed and had not identified all the hazards we had found during our visit.” from the report
Accident investigations
seriousSome accidents and incidents were investigated, but others were not. The provider said it would investigate them fully and take action to prevent repeats.
“This showed that the management team did not always ensure people's health and safety was protected by not investigating all accidents or incidents and taking action.” from the report
Food checks
needs fixingInspectors found two open food packets that were not stored safely and three out-of-date food products. These had not been found by the home's regular checks.
“During a tour of the kitchen, we found two open food packets which had not been stored safely and also three out of date food products.” from the report
- 01Have all fire doors been repaired so they close properly, and when were they last checked?
- 02What action was taken about the shower heads and the risk of drinking water contamination?
- 03How are knives, hazardous substances and other potentially dangerous items now kept secure?
- 04How are accidents and incidents investigated, recorded and followed up to prevent them happening again?
- 05What has changed in the health and safety audit process since the inspection, and how do you check that it identifies all hazards?
This was an unannounced inspection covering all five CQC questions, including conversations with people, staff, the registered manager and relatives, and checks of records and the premises. This explanation was written from the published report of 5 July 2017 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 (Seven Kings)
4 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015Goodstayed GoodSafe: Requires improvement
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 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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