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.