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Beulah Lodge Rest Home Limited Good

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


Updated 12 January 2016

The inspection was carried out on 24 November 2015 by two inspectors. It was an unannounced inspection. The home provides personal care and accommodation for a maximum of 20 older people. There were 20 people living there at the time of our inspection. All the people living in the home were able to express themselves verbally.

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.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm.

There was a system to record and monitor accidents and incidents to identify how the risks of recurrence could be reduced. There were sufficient staff on duty to meet people’s needs. Staffing levels were calculated and adjusted according to people’s changing needs. There were safe recruitment procedures in place which included the checking of references.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

All fire protection equipment was serviced and maintained.

People’s bedrooms were personalised to reflect their individual tastes and personalities.

Staff knew each person well and understood how to meet their support needs. People told us, “Every need is covered here” and, “The staff and I know each other very well indeed, I bet they can hear my thoughts by now”.

Staff received essential training and had the opportunity to receive further training specific to the needs of the people they supported. All members of care staff received regular one to one supervision sessions and were scheduled for an annual appraisal. This ensured they were supporting people to the expected standards.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There was a system to submit appropriate applications to restrict people’s freedom considering least restrictive options as per the Mental Capacity Act 2005 requirements.

Staff sought and obtained people’s consent before they helped them.

The service provided meals that were in sufficient quantity and met people’s needs and choices. Staff knew about and provided for people’s dietary preferences and restrictions.

Staff communicated effectively with people, responded to their needs promptly, and treated them with kindness and respect.

People were satisfied about how their care and treatment was delivered. Relatives told us, “The quality of care here is second to none” and, “The staff are amazing, so kind and patient.”

People were involved in their day to day care. People’s care plans were reviewed with their participation and relatives were invited to contribute.

Clear information about the service, the facilities, and how to complain was provided to people and visitors. The activities programme was provided for people in a suitable format which made it easy to read.

People were able to spend private time in quiet areas when they chose to. People’s privacy was respected and people were assisted in a way that respected their dignity.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, likes and dislikes and preferred activities. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People’s individual assessments and care plans were reviewed monthly with their participation and updated when their needs changed.

People were involved in the planning of activities and told us they were satisfied with the activities provided.

The service took account of people’s feedback, comments and suggestions. People’s views were sought and acted on. The registered manager sent satisfaction questionnaires regularly to people’s relatives or representatives, analysed the results and acted upon them. Staff told us they felt valued under the registered manager’s leadership.

The registered manager notified the Care Quality Commission of any significant events that affected people or the service. The registered manager kept up to date with any changes in legislation that may affect the service and carried out audits to identify how the service could improve. They acted on the results of these audits and made necessary changes to improve the quality of the service and care.

Inspection areas



Updated 12 January 2016

The service was safe.

Staff were trained to protect people from abuse and harm and knew how to refer to the local authority if they had any concerns.

Risk assessments were centred on the needs of the individuals and there were sufficient staff on duty to meet people’s needs safely.

Safe recruitment procedures were followed in practice. Medicines were administered safely.

The environment was secure and well maintained.



Updated 12 January 2016

The service was effective.

Staff were trained and had a good knowledge of each person and of how to meet their specific support needs.

The registered manager understood when an application for DoLS should be made and how to submit one. Staff were trained in the principles of the MCA and the DoLS and were knowledgeable about the requirements of the legislation.

People were supported to be able to eat and drink sufficient amounts to meet their needs and were provided with a choice of suitable food and drink. People were referred to healthcare professionals promptly when needed.



Updated 12 January 2016

The service was caring.

Staff communicated effectively with people, responded to their needs promptly, and treated them with kindness, compassion and respect.

Staff promoted people’s independence and encouraged them to do as much for themselves as they were able to.

People’s privacy and dignity was respected by staff.

People were consulted about and involved in their care and treatment



Updated 12 January 2016

The service was responsive.

Staff were attentive to people’s individual needs and requirements.

People’s care was personalised to reflect their wishes and what was important to them. Care plans and risk assessments were reviewed and updated when needs changed. The delivery of care was in line with people’s care plans.

The service sought feedback from people and their representatives about the overall quality of the service. People’s views were listened to and acted on.



Updated 12 January 2016

The service was well led.

There was an open and positive culture which focussed on people. The registered manager operated an ‘open door ‘policy, welcoming people and staff’s suggestions for improvement.

The staff felt supported and valued under the registered manager’s leadership.

There was a robust system of quality assurance in place. The registered manager carried out audits and analysed them to identify where improvements could be made. Action was promptly taken to implement improvements.