14 March 2023
During an inspection looking at part of the service
About the service
Beachview is a residential care home registered to provide care for up to 10 young people.. It provides support to people who have a range of learning disabilities, some of whom also have a physical disability. At the time of our visit there were 9 people living at the service
People’s experience of using this service and what we found
The provider could not demonstrate how the service met the principles of right support, right care, right culture. This meant we could not be assured of the choices and involvement of people who used the service in their care and support.
Right Support
People’s support needs and risks associated with their care were not always appropriately managed to ensure safe care could be provided. The provider did not have effective systems in place to protect people from avoidable harm. When people expressed choices, these were not always respected due to the deployment of staff. Staffing levels prevented people from getting up when they wanted to.
Right Care
Systems and processes were not always effective in ensuring people were protected from the risk of abuse and staffing was not always provided in line with people’s needs. The service did not have enough staff to meet people’s needs and keep them safe.
People were given their medicines in a way that met their individual needs. However, record keeping was not consistent, nor were we assured that medicines were always administered as the prescriber intended. There were systems and processes in place for the safe storage of medicines. However, these processes were not always followed. We have made recommendations regarding management of medicines.
Right culture
The service did not have a registered manager. The area manager was overseeing the running of the service. Staff told us there was a lack of leadership. Staff and relatives expressed concern regarding the high turnover of managers. Staff spoke of a blame culture at the service and did not feel confident concerns raised were dealt with.
Care was not always person centred and people were not empowered to influence the care and support they received. The service was not using governance processes effectively to learn lessons or improve the service. Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs.
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 requires improvement (published 13 October 2022).
Why we inspected
We undertook this inspection to assess that the service is applying the principles of right support, right care, right culture.
We received concerns in relation to medicines, the management of people’s food, the accuracy of record keeping, staffing numbers, staff culture, leadership and oversight of practices. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report.
We looked at infection prevention and control measures under the safe key question. We look at this in all inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
We will continue to monitor the service and will take further action if needed.
We have identified continued breaches in relation to safe care, the management of the service and governance at this inspection. We have identified a new breach in relation to staff deployment.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Beachview on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme.
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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.