The Beeches Residential 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 inspection we rated this key question good. At this inspection 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, staffing, the Mental Capacity Act, the ways people’s medicines were managed and the safety of the premises.

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

While incidents were reported and investigated, there was limited assurance that learning was consistently identified, effectively shared, and embedded into practice across the service. Opportunities to review trends, recognise recurring themes, and drive sustained improvements were not always fully utilised. Further development of governance arrangements was needed to strengthen oversight, enhance the dissemination of learning, and ensure that quality and safety improvements were regularly evaluated for their long-term effectiveness.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Care plans and risk assessments were not always accurate, current, or reflective of people's individual needs and circumstances. We found examples where information contained within care records did not consistently correspond with people's presenting needs, preferences, or the support they required. Records did not always reflect changes in people's health, wellbeing, or support requirements, and risk assessments were sometimes incomplete or lacked clear guidance on how identified risks should be managed. These shortcomings increased the risk of inconsistent care and reduced assurance that people received safe, coordinated support that reflected their individual circumstances and needs.

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 staff and leaders demonstrated an understanding of their safeguarding responsibilities and were able to describe the appropriate actions required to protect people from harm. However, possible safeguarding concerns were not consistently responded to or recognised so therefore had not consistently been escalated or managed in a timely and consistent manner. We observed potential safeguarding concerns during the inspection that were not identified by the staff. This meant in several instances prompt referrals to the local authority safeguarding team or submitted required notifications to the Care Quality Commission (CQC) were not made by the staff or leaders. These delays reduced opportunities for concerns to be independently reviewed and investigated at the earliest time. Following our inspection visit the provider took action to address these concerns and review care records.

The provider had safeguarding policies and procedures in place and staff had completed training for safeguarding adults. Staff told us they reported any concerns and told us they would also follow the whistleblowing policy if needed. One staff member said, “If there were any issues I would talk to my senior carer, then [they] would speak to the manager, so [they] can contact CQC or put a safeguarding referral through.”However, we were concerned that potential safeguarding concerns were not always recognised by staff.

The provider did not a work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records required review and improvement to ensure they accurately reflected people's current needs, preferences, and the support required to manage identified risks safely. We found that information within care plans was not always sufficiently detailed, person-centred, or consistent across records. In some cases, documentation did not provide staff with clear guidance about the actions required to support individuals safely and effectively, including how to reduce known risks while promoting independence and choice. While some staff demonstrated a good understanding of people's needs, this approach did not provide assurance that support would be delivered consistently, particularly by new, agency, or less experienced staff.

The provider began taking action to make improvements to the care planning and risk assessing processes immediately following our inspection visits. They told us they would undertake a full audit of all current care plans and risk assessments against best-practice standards.

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

The environment was not always managed in a way that ensured risks to people were adequately identified, assessed, and mitigated. We found a number of environmental hazards that had not been appropriately addressed, which placed people at an increased risk of harm. Multiple staircases within the service were accessible without restrictions or effective control measures in place, despite presenting a potential risk to some people living at the service. Risk assessments relating to the use of staircases were not sufficiently detailed or robust and did not adequately consider the needs of individuals who experienced confusion, had mobility support needs, or demonstrated a reduced awareness of danger. Following our inspection visit the provider took action to seek external specialist advice to support the assessment and management of these risks.

We also found that the overall condition of some areas of the environment did not support a safe or well-maintained setting. A significant amount of furniture throughout the service was worn, damaged, or in poor repair. Following our inspection visit the provider took action to replace all damaged furniture.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing arrangements were not consistently sufficient to ensure people received timely, person-centred care and support. During the inspection, we found staffing levels not always enable staff to respond effectively to people's individual needs. Many people using the service had complex care requirements, including advanced dementia, and needed regular reassurance, supervision, meaningful engagement, and ongoing support throughout the day. However, staff were often occupied with routine care tasks and operational duties, reducing opportunities to provide personalised interaction and responsive support.

Although staff were caring and committed to supporting people, the demands of their workload limited opportunities to provide meaningful individual engagement. Staff had insufficient time to spend with people beyond completing essential tasks, reducing their ability to offer reassurance, engage in conversation, and respond proactively to emotional and social needs. This task-led approach did not demonstrate staffing arrangements that consistently enabled care to be delivered in line with people's preferences or in a way that promoted their wellbeing.

Following our inspection visit the provider took action to increase the staffing levels. We were told there would be a minimum of 2 additional care staff during the day and additional staff at night, where required, to mitigate the risks associated with insufficient staffing, support the delivery of safe and person-centred care, and provide assurance that people's needs could be met consistently and without avoidable delay.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not always effectively assess, monitor, or manage the risk of infection within the service. Systems and processes designed to identify and control infection prevention and control (IPC) risks were not consistently effective, and concerns were not always promptly escalated to relevant agencies or professionals where required.

During the inspection, we observed a number of environmental cleanliness concerns. Several areas of the home were not maintained to an acceptable standard of hygiene, including some items of furniture and carpets, which were visibly stained, worn, or difficult to clean effectively. These could increase the risk of cross-contamination and did not support the delivery of care within a clean and hygienic environment.

Following the inspection visit, the provider responded by beginning to address some of the concerns identified, including replacing items of furniture that were no longer suitable for effective cleaning and infection control purposes. While these actions were positive, further work was required to ensure all areas of the environment were maintained to an appropriate standard.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The service had systems in place to manage and administer medicines; however, we identified a number of concerns relating to medicines governance, record-keeping, and oversight which reduced assurance that medicines were always managed in a safe and effective way. Staff did not always have enough guidance to safely administer medicines prescribed on an "as required" (PRN) basis, and some medicines intended for occasional use were being given regularly without evidence of appropriate review.

There was insufficient oversight of medicines given in modified or covert forms. Covert administration arrangements had not always been reviewed within expected timescales, and records did not consistently show that legal and best practice requirements, such as assessing mental capacity, confirming refusal of medicines, and considering alternative formulations, had been followed.

Medicines records were not always complete or person-centred. Important information, including allergies, sensitivities, medicine profiles, and preferred administration methods, was sometimes missing. In addition, medicines administration records were not always fully completed, making it unclear whether medicines had been given as prescribed.

Concerns were also identified regarding medicine storage. Fridge temperatures frequently fell outside the required range, creating a risk that medicines may have become ineffective or unsuitable for use. There was limited evidence that the service had investigated these temperature breaches or sought professional advice about the safety of affected medicines.

Immediately following our inspection, the provider sent us an action plan outlining their plans to make the necessary improvements. These including updating covert administration records and improved medicines records.