Archived: Beacon House Nursing Home

Updated 10 September 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was prompted by the inspection of a second nursing home owned by the provider which was inspected in April 2018. The nursing home was rated as Inadequate and placed in special measures.

This comprehensive inspection took place on 25 and 27 July 2018 and was unannounced.

The inspection was carried out by two inspectors, a CQC graduate analyst and a member of the CQC medicines team.

The provider had completed a Provider Information Return (PIR) in April 2017. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed the information sent to us in the PIR and notifications we had received from the provider. Notifications are for certain changes, events and incidents affecting the service or the people who use it that providers are required to notify us about.

During the inspection, we spoke with three people who used the service, the provider, care coordinator, clinical lead and six staff including care workers and the chef. We also looked at records, including 11 people’s care plans, six care worker records, medicines administration records and records relating to the management of the service. We also spoke with the local authority to obtain feedback regarding the home.

Updated 10 September 2019

We undertook an unannounced inspection of Beacon House on 25 and 27 July 2018. The inspection was prompted by the inspection of a second nursing home owned by the provider which was inspected in April 2018. The nursing home was rated as Inadequate and placed in special measures.

Beacon House is a ‘care home’. 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. Beacon House can provide accommodation and nursing care for up to 22 people with general nursing needs and end of life care. At the time of the inspection 18 people were receiving care at Beacon House.

We last inspected Beacon House on 17 October 2017 and it was given an overall rating of Good with safe being rated as requires improvement without any breaches of Regulation.

At this inspection of 25 and 27 July 2018, we have rated the service inadequate.

At the time of the inspection a manager registered with the CQC had not been in post since November 2015. The service is owned by an individual who was registered to provide one other care home. The provider told us they were considering asking the care coordinator to apply to be registered as the manager for Beacon House. A registered manager is a person who has registered with the Care Quality Commission 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.

People were at risk because they did not receive their medicines in a safe way.

Processes were not in place to ensure the risk of infection was reduced for people using the service. People were placed at further risk because cleaning products and other chemicals were not stored in a safe way.

Risk management plans were not in place to provide care workers with the information to enable them to mitigate these risks when providing care.

Incidents and accidents were not always recorded and investigated so appropriate actions could be taken to reduce the risk of reoccurrence.

The provider had an induction process but records were not completed to demonstrate new staff had undertaken this and had been assessed as competent.

Window restrictors were in place but not used correctly to reduce risk of falls. Some fire doors were not able to close fully which prevented them working as they should.

Personal Emergency Evacuation Plans did not provide sufficient and up to date information to enable people to be evacuated safely from the home in care of an emergency.

People told us they felt safe when they received care at the home but we saw processes for the investigation and review of safeguarding concerns had not been followed.

The recruitment process was not robust as appropriate references were not always in place before assessing applicants’ suitability for the role.

The provider did not deploy adequate number of staff to meet people's support needs.

People did not have maximum choice and control of their lives and staff practices were restrictive.

The service was not always caring as staff did not have enough time to give people they support they needed.

People’s care plans did not include the person’s wishes about how they wanted their care provided as they were focused on care tasks. Records did not provide up to date information relating to people’s care. There were no structured activities planned that met people’s areas of interest and were meaningful.

The provider had audits in place but these did not identify areas where improvement was required

People knew how to raise complaints or concerns relating to the care they received.

People told us they were happy with the food choice and how it was provided.

We found eight breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to person-centred care (Regulation 9), dignity and respect (Regulation 10), need for consent (Regulation 11), safe care and treatment of people using the service (Regulation 12), safeguarding service users (regulation 13), good governance of the service (Regulation 17), staffing (Regulation 18) and fit and proper person employed (Regulation 19)

We are taking action against the provider for failing to meet regulations. Full information about CQC’s regulatory responses to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.