Beeches

About the service

Beeches is a residential care home providing personal care to 11 people at the time of the inspection. The service can support up to 12 people.

People’s experience of using this service and what we found

People were not always supported by enough staff to meet their care needs. The provider’s assessment of the minimum safe staffing levels did not include some people’s support needs. Staffing issues meant people did not always receive the one-to-one support they needed.

The provider’s safeguarding process was not always consistently applied, and an incident of alleged abuse was not notified to the CQC and local authority safeguarding team by the provider. This is something the provider is required to do.

People’s living environment had improved since the last inspection and was now clean and hygienic. Staff had improved the hygiene and homeliness of some people’s bedrooms, which we had raised concerns about at the last inspection. People were protected by the provider’s COVID-19 infection prevention and control measures.

People’s individual risks were identified by the provider and care plans were personalised and comprehensive. People were supported by the provider’s multi-disciplinary care team who had increased their presence in the care home since our last inspection.

People’s prescribed medicines were managed, recorded, and administered safely. People’s individual risk assessments and care plans had been reviewed and updated to ensure they provided an appropriate guide for staff.

People were supported by staff who had received the necessary training to be able to safely meet their care needs. Staff knew how to support them safely and in line with their individual risk assessments and care plans.

People were supported to eat and drink enough to be healthy. Following a recent death of a person, the provider had reviewed and enhanced their support for people who may be at risk of choking on food.

People had access to various activities within the care home and also access to a vehicle for trips out to activities in the community.

People’s relatives told us that communication with them, from the service, had recently started to improve.

Right Support

People did not always receive person-centred care due to staffing issues; and some people's specific support needs were not always clearly identified in their care plans. The service enabled people to access specialist health care support from the provider’s own in-house multi-disciplinary care team.

Right Care

Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care. The service gave people care and support in a safe, clean, well equipped, well-furnished and well-maintained environment that met their sensory and physical needs.

Right culture

The service had recently started to become more open with external agencies and the families of the people they supported. However, that change in approach was not yet fully embedded. Staff did everything they could to avoid restraining people. The service recorded when staff restrained people, and the provider reviewed those incidents to see how they might be avoided or reduced.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Inadequate (published 5 October 2021) and there were five breaches of regulations. The provider completed an action plan after the last inspection to show what they would do, and by when, to improve.

This service has been in Special Measures since 5 October 2021. During this inspection the provider demonstrated improvements had been made in some areas. Although we found the provider was still in breach of one regulation the service is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check whether the Warning Notices we previously served in relation to Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has changed following this focused inspection and is now rated Requires Improvement.

The inspection was also prompted, in part, by notification of a specific incident; following which a person using the service died. This incident is potentially subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns about the management of people’s choking risks. This inspection examined those risks.

We also assessed whether the service is applying the principles of Right support right care right culture.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home 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.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continuing breach of regulation 18 in relation to staffing levels at this inspection.

Follow up

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.

Beeches is a residential care home providing personal and nursing care to 12 people aged over 18 at the time of the inspection. Beeches can support up to 12 people across two separate wings, each of which has separate adapted facilities. The service specialises in providing care to people who have autism and/or learning disabilities, often accompanied by complex behaviours that may challenge.

People’s experience of using this service and what we found

People were not always protected by the provider’s safeguarding processes and procedures. Allegations of safeguarding incidents were not always notified to the appropriate statutory agencies and incident reports were not always accurate or effectively reviewed.

People were not always supported by enough staff to meet their assessed needs. People’s individual risks were not always effectively managed. Some people’s medicines were not always well managed and the provider’s medicine records were not always as accurate as they should be.

Some people’s bedrooms were not hygienic and cleanliness in the care home needed to be improved. Staff did not always wear their personal protective equipment (PPE) face masks in accordance with current COVID-19 guidance.

People were not always consistently supported, and staff did not always follow the guidance created by the provider’s own multidisciplinary team. The provider did not effectively assess people’s compatibility with existing residents before moving new people into the care home.

People’s dietary and hydration needs were not always well monitored.

Some people had bedrooms which were clean, pleasant and personalised. Other people had bedrooms which were impersonal and appeared institutional. There were communal rooms available containing leisure and activity equipment which people could chose to use.

The provider’s quality monitoring and audit processes were not effective in identifying issues and supporting improvements to be made and the sharing of lessons learned.

Staff protected people from injury but there was a high frequency of incidents at the care home in which staff members were injured.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. People's living environment did not always promote their dignity and rights. People’s compatibility was not always considered when new people moved into the service. Although people had person centred support plans in place staff did not always follow them. Staff did not always follow the person-centred support plans when incidents occurred and relied on the use of restraint or temporary seclusion. Managers in the service had allowed a culture to develop in which incidents, restraint, and staff injuries, had become normalised.

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 Good (published 9 May 2018).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about restrictive care practices and staffing levels. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with management practices, people’s living environments, and the management of people’s prescribed medicines, so we widened the scope of the inspection to become a focused inspection which included the key questions of Safe, Effective and Well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home 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.

The overall rating for the service has changed from Good to Inadequate This is based on the findings at this inspection. 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 Beeches on our website at www.cqc.org.uk.

Enforcement

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.

We have identified breaches in relation to safeguarding, staffing levels, safe care and treatment, person centred care, governance and quality monitoring processes.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

¿ Most of the people living at the service required one to one care and support. This meant that staff were able to occupy people isolated in their rooms when they could not access communal areas.

¿ Communal areas were spacious, so it was possible to socially isolate people in the same room when eating or relaxing.

¿ The service was spilt into two areas. Staff and people living at the service stayed in their zoned areas to reduce the risk of cross infection.

¿ The provider had obtained a large supply of PPE (Personal Protective Equipment) and staff had stations to put on, remove and dispose of PPE safely.

¿ Cleaning had been increased, and frequent touch points were cleaned regularly.

¿ Regular testing of people and staff was in place. The service had been supported by the infection control team who provided extra training in PPE use and handwashing.

¿ The service used various methods to communicate information about COVID-19 and PPE to people living at the service to reduce anxieties.

¿ There were easy read posters and social stories to explain and help people understand what was happening.

¿ The service had implemented a picture chart for people who could not speak, to help them to identify and express if they had signs or symptoms of COVID-19.

¿ The service supported people to maintain as normal a life as possible to reduce the distress change would cause. People still went out for walks to get fresh air.

¿ The registered manager had put in extensive risk assessment for people and staff due to the complexities of people at the service.

¿ For example, it was not always possible for staff to socially distance when supporting people, so staff and people were kept in bubbles to minimise contact.

¿ Externally the service had a large garden that had been utilised for visiting, internally the service had a large lounge prepared to receive visitors when restrictions were lifted.

¿ The management team had supported staff by working additional shifts at night to cover colleagues who were self-isolating.

¿ The registered manager told us staff had worked really hard and supported each other at a difficult time.

Further information is in the detailed findings below.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

At our last comprehensive inspection in June 2015 we rated the service as good. In addition the areas we inspected at a responsive focused inspection in December 2016 were good; this was undertaken in response to concerns about the safety of people living at the service.

This is the second comprehensive inspection of the service. The inspection took place on 6 March 2018. We found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Systems and processes were in place to safeguarding people from abuse; these covered staff recruitment practices and staff training and knowledge on safeguarding procedures. Systems also ensured accidents and incidents were recorded and analysed and steps to improve and learn were identified. Risks, including those risks from medicines and infection were identified and steps identified and taken to reduce known risks to people. Staffing levels were kept under review to ensure people received sufficient staff support.

People’s care was provided in line with the MCA and staff understood the importance of seeking appropriate consent for care and treatment. Staff were supported and trained to have the skills and knowledge in areas relevant to people’s needs. Assessments of people’s needs were in place and included assessments of any health related needs as well as any diverse needs including those in relation to a person’s culture or belief. People’s needs for a balanced diet were met and any specific dietary needs were identified and met. Where people required healthcare from other professionals this was arranged and help to ensure good on-going healthcare support for people. The premises had been changed to meet people’s needs and reflect their hobbies and interests.

The staff team demonstrated a caring approach in their work and understood how to reduce people’s anxieties. Staff were mindful of promoting people’s independence and respecting their privacy and dignity. People were supported to be actively involved in decisions about their care.

People’s care and support reflected people’s preferences and interests and identified what was important to them. People and when appropriate, their relatives, were involved in making decisions about their care. Staff understood how people communicated and they worked in ways to promote people’s involvement by ensuring appropriate methods of communication were used. Systems were in place to ensure complaints could be made and investigated.

Sufficient arrangements were in place to cover the absence of the registered manager. Systems and processes were in place to assess, monitor and improve the quality and safety of services. The service was focussed on achieving good quality outcomes for people using the service and worked in partnership with other health and social care professionals to ensure people received appropriate care. People, relatives and staff had opportunities to engage and be involved in the development of the service.

Further information is in the detailed findings below.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff worked to protect people from the risk of abuse and appropriate action was taken following any incidents to try and reduce the risks of incidents happening again. Risks to people’s health and safety were assessed and plans put into place to reduce risks.

People were supported by a sufficient number of staff and staffing levels were flexible to meet people’s needs. Effective recruitment procedures were operated to ensure staff were safe to work with vulnerable adults. People received their medicines as prescribed and they were safely stored.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with seven care workers, a housekeeper, a cook, an administration officer, the acting manager and the operations manager. We looked at some of the records held in the service including the care files for two people, audit reports and staff training records. We did not speak with people who used the service or observe the care and support they received. This was because we were looking at management systems to see what improvements had been made to these and the guidance provided to staff.

The most recent registered manager left the service in September 2014. A new manager had been recruited and the operations manager told us they would apply to become the registered manager once they take up their position. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

This is a summary of what we found-

At the previous inspection we issued a warning notice for Regulation 11 of The Regulated Activities Regulations 2010, Safeguarding service users from abuse and for Regulation 10 of The Regulated Activities Regulations 2010 Assessing and monitoring the quality of service provision.

We found at this inspection some improvements had been made, however there were further improvements needed. Staff had been informed how they should pass on any concerns they had, however we found none of the managers had not been made aware of a concern within the timescale expected to ensure prompt action was taken.

Staff had been informed on what restraint was permitted, however bank staff were not clear about this.

Staff we spoke with understood the policies and procedures about how to keep people safe from harm and knew how to respond to any concerns about people's safety. Staff had been able to reduce the number of incidents of restraint through following alternative ways to keep people safe.

People's support plans had been rewritten so they gave clear guidance about what support people needed and how this should be provided.

When bank staff were used they did not receive the information they needed about events in the service or changes to people's support plans.

There were improvements needed to how shifts were organised. It was not always made clear who was in charge of the shift and there were not planned breaks for staff incorporated into the 12 hour shifts. As a result some staff did not have a break in that time.

The acting manager had made improvements to how the service was run and provided staff with the leadership they required. The acting manager ensured any actions identified in audits of the service were taken.

There was a registered manager in post who was on leave at the time of our inspection.

The inspection team who carried out this inspection consisted of two inspectors and a specialist advisor. We carried out this inspection to answer five key questions; is the service safe, effective, caring, responsive and well-led. Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found-

Is the service safe?

We found there had been problems obtaining the correct equipment to support someone to have a bath. This meant staff had had been supporting the person with their bathing without the correct equipment needed to do so safely.

Although staff we spoke with demonstrated they understood the safeguarding policies and procedures and knew how to respond to safeguarding concerns, we found this had not happened in practice. We found allegations of abuse had not been responded to correctly. We found examples where allegations of inappropriate physical force and inappropriate use of restraint had been made, and these policies had not followed. We also found not all staff had received planned supervision about keeping people safe and how to respond to any allegations of abuse, or completed the safeguarding training they were expected to have.

We found the position about what was, and what was not, acceptable forms of restraint to use were unclear. Staff received training in the use of pressure holds, which may inflict pain, and these were referred to in some people's support plans. However the deputy manager said staff should not use these.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider had followed the correct process to submit applications for a DoLS where it was identified a person needed to have their liberty restricted in order to care for them safely, and that this was in their best interests.

There was a locked door policy at the home which restricted people who used the service from moving around all areas of the home freely. There was no information in people's support plans to show that the effect of this was considered for each person.

Is the service effective?

Any new person coming to use the service had an individual programme for moving to the home developed to help them with the transition from their previous placement.

We saw meetings designed to review and plan people's care did not always discuss issues of need and did not follow up on discussions from previous meetings.

Staff felt the induction for new staff was good and prepared them for their work. However, we found the intended support after this to support staff in their new role was not provided. Staff had not undertaken all the training they required and did not receive ongoing supervision or support. Staff meetings had stopped taking place since April 2014.

Is the service caring?

We found staff responded to people in a caring and respectful manner. We saw there were staff available to give assistance where needed.

One person who used the service told us they were, 'Aright.' They also said that staff were, 'OK.' No one else was able to share their views with us verbally so we spent time in communal areas observing daily routines and people's interactions with staff. We saw that staff were caring and offered compassionate support.

Is the service responsive?

Staff told us where someone did not have the capacity to make a decision they would make that decision for the person in their best interest. Staff told us their training included how to determine if someone had the capacity to make a decision and if they did not, how a decision should be taken in the person's best interest.

We saw that support plans were well organised and detailed, although some information was contradictory and this could lead to confusion about what support people may require. We also found some support plans were not up to date so could not be relied on to describe people's current needs and the support they required. Additionally some support plans did not reflect people's individual health and mobility needs, which would influence the support the person needed.

Staff made referrals to health and social care professionals when people's needs changed and people who used the service were supported to attend health appointments. We found staff were knowledgeable about people's health and social care needs.

Is the service well-led?

Managers at the home did not have sufficient time to complete all their management responsibilities. The deputy manager said, 'There is a lot more we need to do, but we haven't the time to do it.'

There were internal and external audits that had highlighted a number of improvements that were needed but there was no system in place to effectively implement these. As a result a number of recommended improvements had not yet been made. Quality assurance programs had not been properly maintained so information the provider used for monitoring the service was not available, and this had not been recognised. The nominated individual said, 'The robust company systems have not been kept up.'

We found the policies and procedures in use were used by a number of other services operated by the provider and were not always relevant to this service. For example the medication policy had references to a registered nurse when there was not one employed at this service.

We reviewed all the information we had received from the provider. We spoke with the relatives of two people who were using the service. We spoke with the registered manager, the chef and three support staff. We also looked at service information, support plans and performed a partial tour of the building.

We found that comprehensive assessments were undertaken prior to people gaining residency at the home to determine if their needs could be met.

Systems were in place to ensure that consent was sought from people's relatives and they told us they felt fully involved in the decision process.

We saw that people were provided with varied, appetising and nutritionally balanced meals and any specialist diets that were required due to pre-existing medical conditions or cultural needs could be supplied.

We found that the premises were maintained to a very good standard of hygiene and were comfortable and well maintained.

There were sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the individual needs of people.

We saw that systems were in place to enable people to complain or make comments about the quality of the service they received.

Relatives of people who were using the service told us that they were extremely satisfied with the quality of service provision. Comments included, 'The staff are excellent, it really shines through. They all go that extra mile for the residents.' Another person said, 'The attitude of the staff is very good, they are professional, and it's a beautiful home'

Systems had been initiated to ensure that support staff were provided with comprehensive details about peoples' individual needs and preferences in relation to the type of support provided.

Effective recruitment processes were in place to ensure suitable staff were employed at the home and staff had received a thorough training package.

Effective quality auditing procedures were undertaken and appropriate systems were in place for gathering, recording and evaluating information about the quality of the service provided.

We found that all areas throughout the home were maintained to an exceptionally high standard of hygiene and d'cor.