- Care home
The Beeches Residential Home
We served a warning notice on S & A Care Limited on 7 September 2026 for failing to ensure good governance and oversight at The Beeches Residential Care Home.
Assessment report published 28 September 2026
Contents
Ratings
Our view of the service
Date of inspection 20 July 2026 to 1 September 2026.
The Beeches Residential Care Home is a care service registered to support 44 people. At the time of our inspection, there were 37 people living at the service, many of whom were living with dementia. We carried out this inspection due to the length of time since the previous inspection.
At this inspection we found 6 breaches of the legal requirements in relation to dignity, mental health act, safe care and treatment, premises and equipment, staffing and good governance.
This service supports a large number of people living with advanced dementia, many of whom require high levels of supervision, reassurance, meaningful engagement and specialist support. Staff were generally observed to be caring, compassionate and committed to people's well-being, and relatives were positive about the kindness shown by staff. However, the service was not consistently organised or resourced in a way that enabled people to receive safe, effective and person-centred care.
Many of the concerns identified were linked to insufficient staffing levels, ineffective deployment of staff and weaknesses in leadership oversight. Although staff knew people well and were well intentioned, there were not always enough staff available to provide the level of personalised support required. As a result, care was often task-focused rather than centred around people's individual preferences, choices and wellbeing. People were not always supported to maintain their independence, choice and control, particularly during busy periods of the day.
The inspection also found that staff did not always have access to sufficiently detailed dementia-specific training. As many people living at the service experienced advanced dementia and behaviours associated with distress, staff were at times faced with complex situations they did not feel fully confident or equipped to manage. This reduced assurance that people consistently received care informed by current dementia care best practice.
Concerns identified across care planning, risk management, medicines, environmental safety, safeguarding and governance indicated that leadership oversight and quality assurance systems had not been sufficiently effective in identifying and addressing risks. There was no evidence that the provider had been aware of the full extent of these concerns prior to the inspection. Following feedback from the inspection team, the provider responded positively, demonstrated openness to learning and improvement, and sought external specialist support. The provider has also since engaged a dementia care consultant and other specialist professionals to help review practice and support the required improvements. A comprehensive action plan has been developed, with immediate action taken to address environmental risks, staffing levels, care records, medicines management and governance arrangements. While these actions were positive, many remain at an early stage and require embedding to ensure sustained improvement.
Overall, whilst staff demonstrated kindness and commitment to the people they supported, the service was not consistently delivering care that was safe, responsive and person-centred for people living with advanced dementia. Improvements were required to strengthen governance, leadership, staffing, dementia care practice and oversight.
People's experience of this service
People's experiences were variable and did not consistently reflect person-centred care. While many people appeared comfortable in the presence of familiar staff and relatives generally spoke positively about the kindness, compassion and commitment demonstrated by the staff team, we were not assured that people consistently experienced care that promoted their independence, choice, control and well-being.
Many people living at the service were living with advanced dementia and relied on staff to understand their individual communication styles, recognise signs of distress and respond promptly to changing needs. Although staff often knew people well and demonstrated genuine care, staffing levels, staff deployment and limited leadership oversight meant people did not always receive timely, personalised support. Opportunities to engage people in meaningful activities, social interaction and therapeutic engagement were frequently missed, with some people spending long periods of time without purposeful occupation or stimulation.
People were not always supported to exercise choice and control over how they spent their day. During busy periods, support was often task-focused and organised around the operational demands of the service rather than individual preferences and routines. This reduced opportunities for people to maintain their independence and make decisions about aspects of their daily lives.
The environment did not always fully meet the needs of people living with dementia. Limited orientation cues, poor lighting in some areas and a lack of dementia-friendly adaptations reduced people's ability to navigate the service independently and could contribute to confusion, anxiety and reliance on staff support.
We also identified occasions where people's immediate needs were not recognised or responded to promptly. This included delays in support during mealtimes and missed opportunities to respond to non-verbal communication, discomfort or signs of distress.
Despite these concerns, there was evidence of positive relationships between people and staff, and relatives largely expressed confidence in the caring approach of front line staff. One relative said, “I am really glad I moved my [family member] to the Beeches.” Another relative commented, “I would definitely recommend the Beeches.We acted on a recommendation and have not regretted the decision. The home has a friendly and caring family feel and I'm confident that staff know my [family member] well and support them with their needs.” A third relative told us, “It has always been reassuring to know that a large proportion of the staff are long standing employees of the Beeches. They go above and beyond to look after [people], you can tell they enjoy their work in the way they interact with [people] with affection and respect. They always have time and nothing seems to be too much trouble.”
Following the inspection, the provider acted promptly to address concerns and engaged external specialist support to help improve outcomes for people living with dementia. While improvement work had commenced, further action is required to ensure people consistently experience safe, effective and person-centred care that maximises their quality of life, dignity, independence and well-being.