The Beeches Nursing and 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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, particularly in relation to fire safety. The provider was aware of the need to improve in this area but had not yet made enough improvement. Fire safety risks in the home placed people at the risk of harm.

This service scored 56 (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 had not always had a consistent proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Records to demonstrate learning from incidents were not available for all incidents prior to November 2024. However, the provider’s approach to safety incidents had improved recently, and new safety incidents were being recorded and used to develop the service. Incidents were now being analysed to identify any trends. The new management team valued and supported a learning culture and staff told us they had no concerns about how safety incidents were now being managed. People and relatives told us people felt safe in the home and felt incidents would be discussed to understand if any lesson could be learnt.

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. People’s assessments and care plans reflected their current needs, and information was shared effectively with partners. A staff member told us, “We collaborate closely with healthcare professionals such as GPs, district nurses, speech and language therapists, and social workers to ensure that residents receive holistic and coordinated care.” People and staff told us they felt care was delivered safely.

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. The provider did not always share concerns quickly and appropriately. Safety incidents and potential safeguarding concerns had not consistently been recorded and reported. It was not consistently clear how the actions taken reduced the risk of incidents reoccurring. Safeguarding procedures and practices had recently been reviewed, and management gave assurances that safeguarding was a high priority, and they knew how to report and respond to concerns. Any recent concerns had been reported to partner agencies. People, relatives and staff knew how to report concerns and told us they had confidence these would be acted on. A staff member told us, “I would talk to my deputy manager or my manager if there were concerns or abuse within the home and I'm very confident they would act upon them.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People had robust risk assessments that were regularly reviewed.

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

There was a breach of regulation in relation to safe care and treatment, specifically around fire safety. Although some fire safety measures were in place, these were not robust and placed people at potential risk of harm. Fire procedures did not demonstrate how everyone could be evacuated from the building safely. Fire drills did not include all staff and needed improvement to ensure staff could respond safely in the event of a fire. The local Fire and Rescue Service had identified some risks in the home and at the time of this assessment these had not been fully addressed. For example, fire risk assessments needed updating and work was needed to ensure the safety of some fire doors. The provider gave us assurances that they were working to meet these and would immediately review the safety concerns. When we visited the home one of the stairwells was cluttered, which presented a fire risk, management took immediate action to clear this area.

There were enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs. However, the provider did not always make sure staff received effective support, supervision and development.

Staff told us that support had improved, and they currently felt they worked well together and with management. Staff had not always received supervision and appraisal, including formal discussions about development, in-line with the providers policy and planned schedules. Staff had training suitable to their roles and people’s needs. People told us staffing had improved. Some commented they had waited for support in the past, but they currently felt they had support when needed. People and relatives felt staff were competent and caring.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff appropriately followed the required infection control guidelines. The home was clean and tidy, and management made regular checks to ensure staff followed infection prevention and control practices.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines practices had been inconsistent and where errors had been made these had not always been reported appropriately. There had not always been enough investigation and learning to ensure errors did not reoccur. The provider was aware of these issues and practices had recently improved. There was improved checks and oversight in relation to medicines to identify and remedy issues sooner.