Beechwood Care Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Inadequate

Our view of the service

Date of Assessment: 22 December 2025 to 5 February 2026. The service is a residential nursing home providing support to older people and people living with dementia.

This was a responsive assessment carried out following concerns received about the service.

At this assessment, we found the quality and safety of care had deteriorated since our previous inspection. Breaches were identified around the quality and safety of the care and treatment provided, and the governance of the service. We also identified a breach around failing to submit notifications to the Care Quality Commission (CQC).

People were not consistently protected from avoidable harm, and there were widespread failures in incident reporting, oversight and learning. These failures contributed to repeated incidents of physical and psychological harm between people using the service, demonstrating ineffective risk management and an unsafe environment.

Medicines were not managed safely. Medicines were not always stored appropriately. Some guidance around the administration of medicines, including ‘when required’ and variable dose medicines was not accurate or detailed. Some liquid medicines were out of date, and one person did not receive a critical medicine for a significant period of time. Laxatives were not always administered as prescribed.

Governance arrangements were not robust, and the provider did not have effective systems to identify, monitor or address risk. Leaders had limited insight into the seriousness and frequency of incidents occurring in the home, and audits did not highlight key issues such as unsafe medicines management and environmental hazards.

The management culture at the start of the assessment did not support staff wellbeing or promote openness. Staff described poor morale, a lack of support and fear of raising concerns. Some people and relatives were also unclear about how to raise issues. A change in manager towards the end of the assessment, and additional provider support, led to early signs of improvement.

Care plans were generally person-centred and reflected people’s needs. The provider engaged with healthcare professionals. We observed improvements in hydration support and environmental cleanliness during day 2 of the assessment. Staff were recruited safely with appropriate pre-employment checks in place. The provider acted promptly when we raised concerns during the assessment.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

People shared mixed experiences about the quality of care and support at the service. Some people told us staff were kind and helped them feel safe. One person said, “The staff make me feel safe. I feel confident they know what they are doing.” Others said staff were usually pleasant, with one relative commenting, “Everybody is friendly, all helpful.” Several relatives told us the home felt welcoming and clean, telling us, “There are always people cleaning.”

However, many people also raised concerns about safety, staffing responsiveness and the quality of personal care. People told us they did not always receive support promptly, including waits when using call bells. One person said, “They don’t come very fast when you buzz them.” Concerns were raised about people’s hydration needs with one relative telling us, “I’ve gone when [person] has been clearly thirsty on a number of occasions.” Relatives fed back that people were often dressed in clothing that did not belong to them and spoke about things going missing such as hearing aids.

Some relatives did not know who the manager was and felt communication needed to improve. One relative told us, “I don’t know who the manager is”, while another said, “I have not been asked for any views at all."