Beechcroft

Updated 2 April 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was completed by three inspectors.

Service and service type

Beechcroft is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Beechcroft is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority Quality Improvement Team, who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with six people about their experience of the care provided. We also spoke with seven members of staff including a regional manager, the registered manager, a nurse, care staff and support staff.

We reviewed a range of records. This included seven people’s care records and five people’s medication records. We looked at recruitment records for four staff employed since the last inspection.

After the inspection

We continued to seek clarification from the provider to confirm the evidence found, we looked at staff training records and records from the provider regarding the oversight of the service.

Following our visit, we have telephone conversations with three people's relatives, two staff members and a health and social care professional who works alongside the service.

Updated 2 April 2022

Beechcroft is a care home that provides accommodation for up to 43 people who require nursing or personal care. The home is over four floors in one adapted building. At the time of the inspection 16 people lived in the home. Some people at the home were living with dementia.

People’s experience of using this service and what we found

There had been significant improvements to the quality and safety of the service. The provider now had oversight of risks at the service and had taken steps to mitigate them. However, there remained some concerns about the quality and effectiveness of certain records relating to people’s care and treatment.

We made a recommendation about the records of people’s care and treatment.

People had individualised care plans in place, these were used to assess risks present when providing people’s care and treatment. Risk assessments and care plans provided guidance for staff which enabled them to care for people safely. Staff also had information to hand to help them keep people safe in the event of an emergency. This had been updated since our previous inspection.

People’s medication was administrated and managed safely. Staff had guidance available regarding people’s medical conditions and the administration of their medication. This helped ensure people’s medication was administered safely and as prescribed.

There were sufficient staff on duty for the service to be safe and to meet people’s needs in a timely manner. The provider had increased the size of the staff team and now made limited use of agency staff. People’s relatives told us that there was enough staff at the home.

There was a system in place for assessing people’s needs, choices and preferences. Staff were knowledgeable about people’s needs, choices and preferences. People were supported to maintain a balanced diet and had a choice of food available. If people were at risk of malnutrition this was assessed and if needed the advice of a dietician was sought. Staff had guidance available to help people with their nutritional needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff supported people to make as many decisions for themselves as possible. One person told us, “I feel like they respect me.” Another person’s relative told us, “They take their time to listen to them.”

The provider had responded effectivity to the COVID-19 pandemic and had took steps in line with government guidance to help ensure people were safe. The environment of the home was clean and well maintained.

There was a positive culture at the home. People told us that staff were attentive to their needs and showed flexibility in meeting their requests. People’s relatives told us that staff at the home communicate and work in partnership with them and involved them in putting together people’s care plans. Staff members told us that they enjoyed working at Beechcroft; they felt appreciated and looked after by the registered manager and provider.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 29 November 2021).

The provider completed an urgent action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations in relation to; Consent (Regulation 11), Safe Care and Treatment (Regulation 12), Staffing (regulation 18) and Good governance (regulation 17).

At our last inspection we recommended that the provider review staffing arrangements at the home; to ensure it had staff who are enabled to fulfil their roles effectively. At this inspection improvements had been made.

This service has been in Special Measures since 29 November 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

At our previous inspection of this service in September 2021; breaches of legal requirements were found. We asked the provider to complete an urgent action plan to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan, had taken action that we told the provider to take in a warning notice and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions, “Is the service safe?”, “Is the service effective?” and “Is the service well-led?”

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Beechcroft on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We recommended that the provider review how records were kept to ensure they are complete, accurate and fit for purpose.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.