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Inspection Summary

Overall summary & rating


Updated 17 August 2018

The inspection took place on 10 and 18 June and was unannounced.

At our last planned comprehensive inspection in September 2017, we found concerns and took enforcement action. We carried out a focused inspection in November 2017 to check on whether improvements had been made. At that inspection, we rated the service was rated Requires Improvement in the Safe and Well led key questions. There were no breaches of regulation but we could not rate the service further from requires improvement because to do so requires consistent good practice over time. At this inspection, we found that improvements had been made and the service is now rated as Good in all of the key questions, and Good overall.

Beech Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Beech Hall is registered to provide accommodation for up to 64 people requiring nursing or personal care. Beech Hall is purpose built and is located in the Armley area of Leeds. At the time of our inspection there were 51 people using the service.

There is a registered manager in post but they were not present at the inspection. 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.'

At our last comprehensive inspection, we made a recommendation that the provider review their training for staff in relation to the delivery of meaningful activities for people living with Dementia. At this inspection, we found staff had completed further dementia awareness training at level two and aimed to provide an in-depth understanding of dementia and how it affected people using the service.

Medicines were managed safely. Staff were knowledgeable and received training around the management and administration of medicines. There were good relations with local healthcare services and the service utilised the contacts for advice. For example, phoning the district nurses to discuss changes in people's needs and to ensure they received timely advice to address these concerns.

People told us they felt safe. We saw that there were pro-active measures in place to monitor people's safety, such as observation charts and analysis of falls data to identify and address risks. There were risk assessments in place where needs had been identified, for example when a person was at risk of falling.

Care staff understood their responsibilities with identifying abuse and reporting safeguarding concerns.

There were enough staff to meet people's needs. The provider calculated staffing levels in line with people's care needs.

The provider had a safe system for the recruitment of staff and appropriate checks were conducted prior to staff starting work, to ensure their suitability for the role. There were sufficient staff on duty to keep people safe and meet their needs,

The home was clean and free from odours throughout. Maintenance checks were completed on the building and equipment, with any areas for repair addressed promptly.

Staff received an induction which included training to help them carry out their roles effectively. Training was updated regularly and staff had their competency checked in relation to the management of medicines. Staff received regular supervision and appraisal of their work performance.

Care plans were written using person centred details, care staff referred to these for guidance and updated them regularly in the event of a person's needs or preferences changing. Records were well documented and there was clear involvement with health professionals in a timely manner when assessed and required. People were

Inspection areas



Updated 17 August 2018

The service was safe.

People received safe care and treatment.

People were safeguarded from the risk of abuse.

Medicines were consistently managed in line with national guidelines.



Updated 17 August 2018

The service was effective.

People were supported to eat and drink enough to maintain a balanced diet.

People were assisted to receive coordinated care and to access ongoing healthcare support.

Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance.



Updated 17 August 2018

The service was caring.

People's privacy, dignity and independence were promoted.

People were supported to express their views and be actively involved in making decisions about their care as far as possible.

Confidential information was kept private.



Updated 17 August 2018

The service was responsive.

People received personalised care that was responsive to their needs.

Suitable provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

There were arrangements to listen and respond to people's concerns and complaints in order to improve the quality of care.



Updated 17 August 2018

The service was well led.

Systems and processes were in place to assess and monitor the service.

Care staff understood their responsibilities so that risks and regulatory requirements were met.

The service worked in partnership with other agencies.