Beacon House

Updated 23 November 2023

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.

Inspection team

The inspection was carried out by 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Beacon House 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. Beacon House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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 and professionals 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 7 people using the service and had discussions with 4 relatives to gain their view of the service. We spoke with 7 staff including the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also had discussions with 5 care and support staff.

We reviewed a range of records. This included 4 people's care records in depth and 9 medication records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including quality assurance audits, training records, key policies and meeting minutes were reviewed.

Updated 23 November 2023

About the service

Beacon House is registered to provide residential and nursing care for up to 40 older people with physical disabilities and those who may be living with dementia. At the time of our inspection there were 34 people using the service.

Accommodation is provided over the ground and two upper floors with various lounges, a dining room, and an accessible garden.

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

There were shortfalls in the assessment of risks to the health and safety of people living at Beacon House. People who had been assessed as having swallowing difficulties and were on a modified diet to ensure they were able to eat and drink safely did not have a choking risk assessment in place.

Nurses practice needed to align with best practice guidance in relation to wound care. Correct procedures were not taking place which meant essential information about people’s pressure wounds was not recorded to ensure the healing process was taking place or not.

Pressure mattress settings did not always match people's weights. We observed 8 mattresses that were not set correctly according to people’s weights. Repositioning charts for pressure area care and food and fluid charts had significant gaps.

Where PRN (as needed medicines) protocols were in place there was no guidance regarding variable doses. For example, when to give 1 tablet and when to give 2 tablets.

We have made a recommendation about the management of as needed (PRN) medicines.

Quality checks and audits needed to be strengthened to ensure areas for improvement were identified and acted upon swiftly. Quality checks had failed to identify the gaps in monitoring charts, incorrect mattress settings, risk assessments not in place, incorrect recording in risk assessments and inconsistencies in recording.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

The registered manager had not always considered or investigated some adverse incidents or reported these to the Local Safeguarding Authority and CQC as required by law.

People were safe because staff knew how to recognise the signs of abuse and how to report it. People and staff felt they would be listened to if they raised any concerns. People received support from staff who had undergone a robust recruitment process. They were supported by regular, consistent staff who knew them and their needs well.

People, relatives, and staff were positive and about the leadership of the service and praised the registered manager. Staff felt well supported and said the registered manager was open and approachable. The service worked in partnership with outside agencies.

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

Rating at last inspection

The last rating for this service was Good (published 28 November 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We inspected and found there was a concern in relation to ensuring consent to care and treatment in line with law and guidance, so we widened the scope of the inspection which included the key questions of safe, effective and well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well-Led sections of this full report.

Please see the action we have told the provider to take at the end of this report.

Enforcement and Recommendations

We have identified breaches in relation to assessing risks, monitoring and management of pressure area damage, nutrition and hydration monitoring, the Mental Capacity Act and quality monitoring of the care people received.

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.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

at this inspection.