Archived: Beaconsfield Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment including shortfalls in people’s medicine management, infection prevention and control and managing risks. In addition, there were also breaches of regulations in relation to fit and proper persons employed and notifying CQC of notifiable incidents at the service.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice. We identified the risk of fire from smoking at our previous inspection in March 2025. However, the provider had failed to take effective learning and there was a smoking related fire at the home in April 2025. While some action was taken to mitigate risks following this fire, learning was not effective, and people continued to smoke within the service. The failure to learn lessons from safety incidents and take robust action to keep people safe places people at risk of harm.

The manager told us they received safety alerts from the government which informed them of upcoming risks, and they acted if they were relevant to the service. However, the provider had failed to take account of all national safety alerts to prevent safety incidents from occurring. The Medicines and Healthcare Products Regulatory Agency (MHRA) issued a safety alert in 2008 warning about the risk of severe and fatal burns from emollients. MHRA updated the alert in 2016 and again in 2018 and in July 2020, MHRA updated its guidance. However, the provider failed to take account of this national safety alert when assessing the increased fire risk to people using emollients due to smoking or being in contact with people smoking, thereby increasing the likelihood of an incident occurring.

Staff feedback was mixed. Some staff told us they received feedback following incidents and other staff told us they did not receive feedback. The manager told us, “Moving forward we are looking at having regular staff meetings…and dedicating a section to lessons learned.”

Where people had been involved in an accident or incident these were reported and investigated; however, learning had not always been shared and robust action taken to mitigate the risks.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The manager could describe the process for when people moved between services including in and out of hospital. The manager told us they use a paramedic information sheet to share basic information with first responders as well as hospital packs. However, because records were not always completed fully and accurately there was a risk, when moving between services, that people would not always be supported according to their needs, wants and wishes.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

The provider failed to safeguard people from harm and neglect as they had not taken action to reduce the risk of fire and passive smoking to people. The provider knew people did not adhere to their no smoking policy and had been alerted to the risk this posed to people’s safety at our previous inspection in March 2025. Despite the known fire risk and risks to others from passive smoking the manager told us eight people still illicitly smoked in the home environment. Four people were nonsmokers and remained at the risk from the harmful health effects of passive smoking. All people were at risk of harm from fire. The service had 2 fires within a 6-month period. The provider continued to provide care in an unsafe environment and failed to take enough robust action following the fires to mitigate the risk of harm to people.

Staff were aware of their safeguarding responsibilities and knew how to recognise different types of abuse and report it internally. However, all safeguarding incidents had not been reported to other agencies, such as CQC, as required. We reviewed care records for 1 person and found 5 allegations of abuse had been reported. This information was raised with the local authority safeguarding team; however, the provider failed to notify CQC of these allegations of abuse. Statutory notifications inform CQC of notifiable incidents and help us to monitor services we regulate.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

At our previous inspection in February 2025, we found people’s smoking risk assessments had not been accurately completed. At this inspection we found the same concerns. For example, significant risks from unsafe smoking in the home had been assessed as insignificant. This meant the seriousness of risk posed to people’s safety was not accurate and control measures in place were not sufficiently comprehensive and robust to reduce the actual risk level. Staff therefore did not have all the information necessary to support people to manage these risks and may not be aware of the severity of risk.

The provider had a no smoking policy in place. However, they were aware people smoked in the home and did not take robust action to mitigate the risk of fire. The provider told us the use of fire aprons had been discussed with people, but they were not interested. One person’s smoking risk assessment did not identify this person illicitly smoked in their bedroom. This placed people at significant risk of harm.

Fire retardant spray was used on bedding in bedrooms of people who smoked. This had not been effective at preventing the risk of fire. For example, the fire in a bedroom which occurred on 30 September 2025 rendered the bedroom unusable.

Some people use emollient creams to keep their skin healthy. There is a risk of severe and fatal burns from emollients if people smoke or go near someone smoking as the cream leaves a residue that can easily ignite. However, this risk had not been assessed accurately. For example, 1 person had a general risk assessment titled, ‘Emollient creams and lotions.’ The risk of using flammable emollients was assessed as low risk. However, the person lived with people smoking in the home and there had been 2 fires at the service in the past year which significantly increased their risk. This person’s bedroom contained significant amounts of paper which further increased the risk of harm in the event of a fire.

Risk relating to people’s behaviour that could place them or others at risks had not been comprehensively assessed. Therefore, robust plans were not in place to guide staff how to keep people and others safe if they became agitated. One person had a general risk assessment in place titled, ‘Verbal and physical aggression when out in the community.’ It stated staff should support the person to feel confident to access the community with support; However, it did not describe how staff were to do this, how to identify if the person was becoming agitated to prevent escalation or what reactive strategies to use if the person was to become aggressive to support them safely. This meant people were at risk of not being supported to manage their anxiety and agitation safely placing them and others at risk of harm.

People at risk of choking were not supported to eat safely. One person had been advised to eat a minced and moist diet to reduce the risk of choking. We observed a lunch time experience. This person was served broccoli which was not minced and moist. This increased the person’s risk of choking. The person was coughing during eating, and the food had to be removed and blended. Staff had recorded the food provided to the person was prepared to a regular texture not minced and moist. This person’s records from the previous 4-weeks showed their food was recorded as being prepared to a regular texture on 10 occasions, this included 3 occasions after 23 September 2025 when we raised the concern with the manager.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

Although following our previous inspection the provider had completed all the actions required by the local Fire and Rescue Service. For example, replacing doors which were not approved fire doors, we found continued environmental risks relating to smoking.

Prior to our previous inspection in February 2025 the provider had been informed by the local Fire and Rescue Service that it was not safe for people to smoke on the external fire escape. At our previous inspection we saw people were being supported to smoke on the fire escape. At this inspection we found cigarette butts on the fire escape. This meant there remained a risk of fire if people continued to smoke on the external fire escape and cigarette butts were not disposed of safely. The provider had removed items from underneath the fire escape which reduced the risk. However, if a fire was to occur this would prevent people from accessing the fire escape.

During our inspection we found the door to the small office was unlocked. People therefore had unauthorised access to potentially harmful products along with scissors and a pointed letter opener. We found a cleaning spray containing bleach was left in 1 person’s bedroom. There was a risk these products could be misappropriated and/or swallowed. We spoke to the manager about this. They removed the product from the person’s bedroom and locked the office door.

The service completed monthly tests of thermostatic mixing valves (TMV) which should limit the temperature of tap water to 44 degrees Celsius to reduce the risk of scalding. However, the checks had not been completed in May, June, July, or August 2025 to ensure the valves effectively controlled safe water temperature as the person responsible for checking these had not been available for an extended period. The valve checks were completed on 17 September 2025, and 3 taps were found to be over 55 degrees, 2 of them over 57 degrees. No action had been taken to rectify this or to mitigate the risk to people at the time of our site visit. We spoke to the manager about this who told us it would be fixed by 27 September 2025. When we asked for further assurances of how this risk would be managed in the interim, the manager told us they had put the 2 toilets and 1 bathroom out of use until they were made safe. We were informed on 30 September 2025 that the work had been completed.

One person’s attic bedroom did not have a window restrictor in place on 23 or 25 September 2025. This put the person at risk of harm from falling from a significant height. This was rectified on 30 September 2025.

The provider did not make sure recruitment processes were followed to ensure sure suitable staff were employed. They did not work together well to provide safe care that met people’s individual needs.

Safe recruitment processes were still not being followed to ensure people were only supported by staff that had been vetted. At our previous inspection in February 2025, we found the provider’s recruitment and selection policy was not sufficiently comprehensive to ensure all pre-employment checks would be completed. This policy also did not robustly cover arrangements that needed to be in place when starting new staff members without checking their criminal records. At this inspection, the provider told us no policies had been updated since the last inspection. However, when we requested the recruitment policy it had been updated in April 2025. The updated policy still did not accurately identify the full requirements of recruitment legislation. Following the inspection the provider updated the policy further; however, it still did not include the requirement to obtain satisfactory verification, so far as reasonably practicable, of the reason why the staff members employment in those positions had ended.

At the last inspection we found the provider had not sought satisfactory evidence of conduct in all previous employment related to health or social care, children, or vulnerable adults. Where staff had been previously employed to work with children or vulnerable adults, the provider failed to obtain satisfactory verification, so far as reasonably practicable, of the reason why the staff members employment in those positions had ended. At this inspection we found the same concerns in relation to staff recruited as identified at our last inspection. The manager told us they were not aware of this requirement.The provider told us they did try and contact previous employers, but they had not always received a response. The provider told us when this occurred, they had not completed a risk assessment to mitigate the risk to people. This meant recruitment procedures were not established and operated effectively to ensure staff were recruited safely.

Most staff attended a fire drill between 3 March 2025 and 5 June 2025. Two staff who attended their last fire drill on 14 April 2025 were identified as requiring further drills and training. Both staff members had not completed online fire training, and no further drills or training had taken place since these further actions had been identified. This put people at risk of harm if staff were unable to evacuate people safely in the event of a fire.

The manager had a training matrix in place which evidenced most staff had completed most of their statutory and mandatory training via e-learning. However, most staff had not completed Positive Behaviour Support (PBS) training. Some people living in the service experienced agitation and anxiety related behaviour. This meant staff may not always have the skills and knowledge to support people effectively when they were at a heightened state of anxiety. Most staff told us they thought the training in general could be better and that e-learning was not always the best way to learn. One staff member told us, “It is all just online training, I prefer hands on, I complete online training but can find you do not take it in. We have spoken about it especially first aid and they [providers] talk about it being expensive and query is it worth it.”The provider told us, “Staff currently complete face to face training in the following courses: Fire training annually and medication training with Portsmouth city council.” Staff had attended autism training to support them to meet people’s needs. One person had some 1 to 1 support and was supported by staff who knew them well.

The provider did not assess or manage the risk of infection. The provider failed to take all reasonable steps to prevent and control the spread of infections. They failed to maintain a clean home environment, increasing the risk of infection.

People’s bedrooms were visibly dirty and contained items that were sticky covered in thick layers of dust and grime, including fans and lamps. Some bedsheets were also found to be unclean. One person’s bedroom had a strong malodour noted during both onsite visits on 23 and 25 September 2025. There were several fans in people’s bedrooms which were visibly dusty and dirty.

We found the kitchen environment was not maintained in a clean and safe way. There was a fan in the kitchen, plugs and tiles that were visibly dirty and sticky. The cooker extractor fan hood was visibly dirty as was the deep fat fryer. This increased the risk of cross contamination when cooking and the spread of bacteria to people.

The room which we were told was a music room was dirty, instruments were covered in dust and were sticky. Effective cleaning had not taken place to prevent the presence of bacteria in the home, increasing the risk of harm to service users. We found very similar concerns at our last inspection.

We found 2 bins which either did not have pedals, or the pedal was broken and the bin in a bathroom which opened via a pedal but did not close without manually closing it. This put service users at risk of harm from the risk of infection due to the risk of cross contamination when physically touching the bin lids.

The provider failed to manage service users’ food safely placing them at risk of exposure to harmful bacteria and ill health. On 23 September 2025 we found rust in the bottom of the small fridge. There were several out-of-date foods including pate, chicken slices, blackcurrant conserve, apple sauce, seasoning and garlic paste. We also observed plated up meals and a piece of cake with no labels indicating when they were plated and refrigerated. This meant people were placed at the risk of harm because eating food past the use by date could lead to food poisoning from harmful bacteria. We found some decanted foods with no labels of when they were opened or when to dispose of them. Some labels on decanted food had the day and month but not the year recorded.

The provider had recently received a food hygiene rating of 2 from the Food Standards Agency (FSA) because rodent droppings were found in the food store cupboard on 2 occasions. The provider has taken action to manage the rodent issue.

The service had a recurring outbreak of bedbugs for several months. On 23 September 2025 bedbugs had again been identified in 1 person’s bedroom. The provider arranged for this person’s bedroom to be treated again. This was carried out on 24 September 2025.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff did not always involve people in planning.

One person was prescribed a high risk antipsychotic medicine. While there was a general risk assessment in place for this person’s refusal of medicines it did not cover the risks associated with this medicine such as increased risk of heart rhythm problems, stroke and sudden cardiac death. There was no information about the signs for staff to look out for and no detail about when to seek medical intervention other than after 3 days of refusal of medicines. This meant staff may not have all of the information necessary to keep this person safe from harm.

We reviewed medicines management records. We found some discrepancies in the medicines stock record compared to what was in stock for 5 medicines. This meant the provider could not assure themselves people had received their medicines according to their prescriptions. This placed people at risk of harm.

We found for 3 people, 1 medicine they were each prescribed was not on their Medication Administration Records (MAR). The provider’s systems and processes had failed it identify these medicines were not on the MAR charts and the person might therefore not have received their medicines as prescribed.

One person was prescribed a blood thinning medicine twice a day to be given 12 hours apart. There were 6 occasions where this medicine had not been administered due to this person being out. There was no evidence this had been discussed with the GP to see what could be put in place to ensure this person received their medicines in line with their prescription. There were 2 gaps in this person’s MAR chart on the morning of the 7 and 8 September 2025. There was no code to identify why the medicine had not been signed for. On the 7 September 2025, this blood thinning medicine was signed for at midday. And the medicine was administered again at ‘Bedtime’ We could not ascertain if the 12-hour gap had been left between these 2 medicines. This meant the person had not received their blood thinning medicine as prescribed placing them at risk of forming dangerous blood clots.

One person was prescribed a regular calming sedative medicine which was not administered in line with their prescription on 17 occasions. This resulted in increased agitation and distress for this person on 13 occasions in September 2025.

The provider was not working to the principles of Stopping over medication of people with a learning disability and autistic people (STOMP). The manager told us there used to be a STOMP folder in place however, they had not been able to find it since they resumed their position at the service. Following the inspection the manager sent us an undated form which showed a monthly tally of how many times medications had been administered and any changes made. There was no explanation why changes had been made. This meant the provider was unable to review and monitor the effectiveness of any changes which placed people at risk of harm.

We found the fridge in the medicines room was found to be over 8 degrees on 5 occasions between 7 and 11 September 2025. On the 21, 22 and 24 September the fridge temperature was recorded as ‘broke’; However, this was still being used to store medicines. This meant the effectiveness of these medicines may be compromised because they were stored outside of the recommended 2 to 8 degree’s range.The provider told us, “The medication fridge was not broke. Staff fail to reset the fridge temperature (thermometer).” We could not be assured the provider was accurately recording fridge temperatures or acting when temperatures were outside of the safe range.