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Beulah Lodge Rest Home Limited Requires improvement

We are carrying out checks at Beulah Lodge Rest Home Limited. We will publish a report when our check is complete.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 October 2018

We conducted an unannounced comprehensive inspection at Beulah Lodge on 10 July 2018. Beulah Lodge is a ‘care home’ for older people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Beulah Lodge accommodates up to 21 people in one building. At the day of our inspection 17 people were living at the home.

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’ The registered manager was also a director of the registered organisation and the Nominated Individual (a Nominated Individual must be employed as a director, manager or secretary of the organisation, with authority to speak on behalf of the organisation. They must also be in a position which carries responsibility for supervising the management of the carrying on of the regulated activity). The management team consisted of the registered manager, a manager, a clerical manager and a team leader.

At our last inspection, published in January 2016 the service was rated as good overall and for all five questions we ask. At this inspection we found some areas which need improvement within safe, effective and well led.

There were health and safety policies, audits and monitoring in place; however, the provider had failed to ensure the environment was safe. The provider could not be assured that people could vacate the premises safely if a fire were to break out. Fire drills had not gone as planned and corrective action had not been taken. We have made a recommendation about this. A first-floor bedroom window was not restricted from opening fully, this put people at serious risk. This was a breach of the Health and Social Care Act 2008 regulations. Post the inspection the provider told us they had taken immediate corrective action with regard to the window restrictor.

The provider did not consistently ensure the safe use of people’s prescribed medicines. Medicines errors were not analysed effectively to prevent reoccurrence; there were not always protocols in place for people who needed medication ‘as and when required’ to ensure people received medicines when they needed them. The failure to ensure the proper and safe management of medicines was a breach of the Health and Social Care Act 2008 regulations. Post the inspection, the provider told us they had taken corrective action.

Accidents and incidents were not always analysed effectively so lessons were not always learned when things went wrong. This is an area for improvement. Individual risks relating to people’s care were managed, systems were in place and appropriate action taken. Safeguarding and whistleblowing policies were in place, concerns had been appropriately reported and staff had received training. Systems were in place which ensured information held about people was secure. There were sufficient staff available to meet people’s needs and safe recruitment practices were completed. Infection prevention and control policies, risk assessments and systems were in place.

People were asked to consent to their care. People’s needs were assessed and people’s care plans detailed their individual needs. Although the provider had meet people’s needs around their communication, they were not aware of the Accessible Information Standard (AIS). We have made a recommendation about this.

Feedback on the choice, quality and amount of food was very positive. People were supported to live healthily and access healthcare. The provider worked with partner organisations to ensure people received the care they needed. The premises had been adapted to meet the mobility needs of people and some consideration had been given to people with dementia and their needs around their environment. Care staff had received an induction, training and on-going support to do their job and received periodic supervision and appraisals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The provider had trained and supported staff to understand the requirements of the Mental Capacity Act in general, and the specific requirements of the DoLS. However, the provider had not always complied with the Care Quality Commission’s (Registration) Regulations 2009 as they had not informed us of two authorised applications for DoLS.

Staff were caring and the provider promoted a person centred culture. This was evidenced in the environment and in the way people were cared for. People’s rooms were personal and reflected their interests. The service was very homely, smelt nice and provided comfortable living accommodation for people. The manager and staff knew the people they cared for well and we saw positive personal interactions between staff and people throughout the day. The provider considered peoples individual protected characteristics under the Equality Act 2010. People were supported to maintain contact with their families and all relatives could visit whenever they wished. Managers and staff encouraged people to be involved with their care. Residents and relatives meetings were held and feedback was sought. Staff respected and promoted people’s needs for independence, privacy and dignity. Confidential information was kept secure and there was evidence that the provider was aware of new data protection laws.

People received personalised care which was responsive to their needs. Care plans and assessments were person centred and described what was important to the person, including their likes and dislikes and were tailored to their individual needs. The provider supported people as they reached and at the end of their life. People’s end of life wishes, where known, were recorded and reflected well in people’s care plans. Staff told us they had received training in end of life care.

People were supported to take part in activities they liked within and outside of the home. We observed an activity within the home and saw that people were either engaged or enjoyed watching and the staff leading the activity was friendly and skilled at engaging people. People and relatives could raise any concerns or complaints they had and complaints were recorded, monitored and managed appropriately.

Audits were completed and an annual development plan had identified areas for development, which was reviewed regularly. There were systems in place to ensure that quality, performance and risks were managed, however these were not always effective. This was a breach of the Health and Social Care Act 2008 regulations. Post the inspection, the provider told us they had taken corrective action.

The provider promoted continuous learning by reviewing survey results and action plans from audits and making improvements. The management team promoted a positive culture, had a visible presence in the service and knew people well. People, relatives and staff were engaged in the service and the provider sought on-going involvement through regular meetings. The managers fed back to people, relatives and staff actions they had taken because of feedback. There were appropriate policies and procedures in place for staff guidance and the managers and staff worked in partnership with a range of healthcare professionals to meet people’s needs.

We noted that the provider had reviewed their Statement of Purpose (a Statement of Purpose is a document all registered providers must have, and which describes what they do, where they do it and who they do it for) but it was no longer in keeping with the regulations. We have made a recommendation about this.

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. This is the first time the service has been rated as Requires Improvement.

Inspection areas


Requires improvement

Updated 19 October 2018

The service was not always safe.

Medicines were not always managed safely.

Premises monitoring checks were carried out but did not always ensure people were protected from environmental risks.

Learning from accidents and incidents was not always evident.

Systems and processes were in place to protect people from abuse.

Risks assessments in relation to people’s care were in place to keep people safe.

There were enough staff to keep people safe and meet their needs.

People were protected from the prevention and control of infection.



Updated 19 October 2018

The service was effective.

People received information in a way they could understand.

Assessed needs were reflected in people’s care plans and reviewed regularly.

Staff had received the right training and support to fulfil their roles.

People were supported to eat high quality and healthy meals and given choice with their food.

People were supported to access healthcare services.

The premises met people’s individual needs and preferences.

Consent to care was sought and systems were in place to assess people’s mental capacity, and to ensure decisions were made in their best interests.



Updated 19 October 2018

The service was caring.

People were offered comfortable living accommodation and bedrooms were individualised.

People were treated with kindness, respect and compassion.

Staff understood and respected people’s privacy and dignity and promoted their independence.

People’s protected characteristics under the Equality Act 2010 were considered.

People and their relatives were engaged with the service and involved in decisions about their care.

Relatives were made to feel welcome and could visit when they wished.



Updated 19 October 2018

The service was responsive.

People’s care plans were person centred, looked at their likes and dislikes, what was important to them and were kept up to date.

There was a good choice of activities on offer within and outside of the home.

Systems were in place to enable people and relatives to complain and the provider acted on feedback they received.

People’s wishes regarding the end of their life were included in their care plans.


Requires improvement

Updated 19 October 2018

The service was not always well led.

The provider had not complied with all the CQC (Registration) Regulations as they had not told us about two DoLS authorisations.

Systems in place to ensure that quality, performance and risks were managed were not always effective.

A positive, person centred culture of continuous learning was promoted by the manager.

The views of people, relatives and staff had been actively sought.

The managers fed back to people, relatives and staff actions they had taken because of their feedback.

Staff worked in partnership with a range of healthcare professionals to meet people’s needs.