Beechwood

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 assessment we rated this key question Good. At this assessment 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 the way people’s medicines were managed safely.

This service scored 56 (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 investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We saw accident and incident forms had been completed in most instances. However, one person’s care records showed 2 instances of unexplained bruising which had not been recorded on an incident form or investigated, although action was taken when we raised this with the provider.

Another person’s care records showed they had been found on the floor in their bedroomin April 2025; however, this was not recorded on the accident and incident analysis for that month.

One person’s pressure reliving mattress was not set to the correct weight placing the person at risk of pressure damage. This had not been identified by staff; however, action was taken when we raised this with the provider.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

Pre-admission assessments were carried out to ensure people’s needs could be met by the service. This included liaising with people, their relatives and other professionals involved in the person’s care. Hospital passports were in place to ensure continuity of care when people were transferred to other services.

The provider generally worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, the provider did not always share concerns quickly and appropriately.

Records showed some safeguarding incidents had been referred to the local authority and notified to the CQC. However, one person’s care records identified 2 incidents of unexplained bruising which had not been reported or investigated. Action was taken when we raised this with the provider.

Information about safeguarding was displayed in the home and staff had received safeguarding adults training.

DoLS authorisations including any conditions, were included in people’s care files.

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

Risk assessments were in place, however, there was a lack of consistency. Some risk assessments were detailed, whereas others needed updating or had not been fully completed. For example, the moving and handling assessment for one person who was immobile, had not been fully completed. Another person’s risk assessments had not been updated since 2024 and did not accurately reflect the current risks to the person. Action was taken when we raised this with the provider.People and/or their relatives were not always involved in the risk management process.

There was a lack of clear guidance to help staff respond safely and consistently to a person’s distressed behaviour when providing care and support. Records showed incidents had occurred, however it was unclear if there had been discussions with staff about what had and hadn’t worked, or that any learning was shared with the team to reduce the risk of re-occurrence. This placed staff and the person at potential risk of harm.

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

People and staff raised concerns about ongoing problems with the heating system and water. Staff, people and relatives said the heating in the building was not reliable or effectively regulated. This meant the temperature was sometimes cold, as we identified on our first site visit, and at other times uncomfortably warm as we found on subsequent visits. One person said, “It saps my energy when it so hot.” Radiators in the dining room were not guarded and had hot surface temperatures posing a risk to people.

People said when showering the water often cut out for several minutes leaving them waiting for it to come back on and when it did the water was spluttering. The provider’s improvement plan showed a contractor had been appointed at the end of September and final plans were in place for works to be completed to address these issues.

There were gaps in the recording of some regular safety checks of the environment. Where issues had been identified it was not always clear what action had been taken to address them.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider used a monthly dependency tool to calculate staffing levels and staff rotas showed compliance with these calculations. Records showed staff were kept up to date with training and received regular supervision and annual appraisals. This was also confirmed in our discussions with staff.

We received mixed feedback about staffing levels. Staff and people said there were usually enough staff, although they said numbers reduced when staff accompanied people out in the community. One staff member said, “Some days are okay but some days we don’t have enough staff to be able to manage. If the residents have medical appointments that require a staff member to escort them then that leaves us short staffed on the floor as that member of staff is taken from the day shift. Sometimes there can be multiple escorts on in a day which leaves us very short staffed.” One person said they had not been able to go out with their 1:1 staff member due to staff shortage.

Recruitment processes were robust with all required checks completed before new staff worked at the service. People who lived at the service were involved in the interview process for new staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and hygienic. Staff had received up to date training in infection prevention and control (IPC). Supplies of personal protective equipment (PPE) were available throughout the service, and we observed staff using PPE appropriately.

Regular IPC audits were carried out to monitor cleanliness and infection control practices. No concerns were raised by people or relatives regarding the cleanliness of the service.

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

We found powder used to thicken drinks to prevent choking was not always stored securely. There was conflicting information about the amount of thickener to be used, and staff did not document when it had been added to drinks. Therefore, we could not be assured drinks were always being thickened safely for people, placing them at risk of choking.

Some people had their medicines administered via a Percutaneous Endoscopic Gastrostomy (PEG) tube, which is a feeding tube inserted into the stomach. Medicine administration records (MARs) and care plans were not clear which medicines should be given via the PEG or how the medicines should be prepared and administered safely. For example, not all tablets or capsules are safe to crush or open and they should only be prepared in this way if an appropriate healthcare professional can confirm that it’s safe to do so. Staff said water flushes were given between different medicines; however, this was not recorded.

Protocols were not always in place for people who were prescribed ‘as required’ medicines. This meant staff did not have clear guidance, alongside the medicine administration records, to inform them when to administer the medicine.

Records were not always fully completed for the care and cleaning of medical equipment such as PEGs and non-invasive positive pressure ventilation (NIPPV) machine.

Medication administration records for topical preparations such as creams were not always completed. One person’s MAR for a cream prescribed to be administered daily had only been signed as given 4 times in 19 days.