The Beaufort Care Home

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 requires improvement because the provider was in breach of the legal regulations in relation to safe care and treatment, premises and staffing. Some improvements were found at this assessment and the provider was no longer in breach of these regulations. However, further improvement was still required. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm.

This service scored 59 (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 had a positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, processes to learn lessons through effective investigations and to identify and embed good practice needed to be improved.

There was a process to report and record accidents and incidents and for those accidents and incidents to be reviewed for patterns and trends. We found 1 medicines incident had been recently reported. However, processes to ensure learning following accidents and incidents was embedded in staff practice were not always effective. For example, following an error involving the application of a medicine administered via a patch, learning was that 2 staff signed to show medicine patches had been removed and applied safely. Gaps in records did not always evidence 2 staff did this. Issues related to fire doors and their effective closure and speed of closure identified at our last inspection continued because we found 4 fire doors that did not close effectively. We could see some actions had been taken, but feedback from staff with delegated responsibilities showed this was a known issue but there continued to be discrepancies in how often and when checks of fire doors should be made. At this assessment we found some previous issues we identified at our last visit around effective monitoring continued so we could not be confident lessons had been fully learnt and embedded into day-to-day practice.

Staff told us they knew how to record an incident or accident and how to escalate safety concerns. Staff explained this information was recorded by them using their electronic monitoring system [PCS]. One staff member told us, “I would check if a person had a fall, check the person is okay, speak with them and ask them. I would then press the emergency bell, and a nurse will attend and then paramedics are called immediately. There is an incident document, if I am the first person attending to the person then I would complete it.”

The provider had a positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, processes to learn lessons through effective investigations and to identify and embed good practice needed to be improved.

There was a process to report and record accidents and incidents and for those accidents and incidents to be reviewed for patterns and trends. We found 1 medicines incident had been recently reported. However, processes to ensure learning following accidents and incidents was embedded in staff practice were not always effective. For example, following an error involving the application of a medicine administered via a patch, learning was that 2 staff signed to show medicine patches had been removed and applied safely. Gaps in records did not always evidence 2 staff did this. Issues related to fire doors and their effective closure and speed of closure identified at our last inspection continued because we found 4 fire doors that did not close effectively. We could see some actions had been taken, but feedback from staff with delegated responsibilities showed this was a known issue but there continued to be discrepancies in how often and when checks of fire doors should be made. At this assessment we found some previous issues we identified at our last visit around effective monitoring continued so we could not be confident lessons had been fully learnt and embedded into day-to-day practice.

Staff told us they knew how to record an incident or accident and how to escalate safety concerns. Staff explained this information was recorded by them using their electronic monitoring system [PCS]. One staff member told us, “I would check if a person had a fall, check the person is okay, speak with them and ask them. I would then press the emergency bell, and a nurse will attend and then paramedics are called immediately. There is an incident document, if I am the first person attending to the person then I would complete it.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People felt safe when receiving support from staff. One person said, “I love the staff they are all so nice to me.” Another person told us, “The staff are marvellous, I can’t fault them.” People said they received care that was safe because staff knew them well. One person told us they required specialist equipment to help them mobilise and they said staff did this safely.

Staff understood how to monitor for signs of abuse and poor practice, as well as escalating concerns. One staff member shared examples of the different types of abuse and said, “Safeguarding is protecting the rights of residents from anything such as physical, mental, verbal or financial abuse.” Another staff member told us, “Safeguarding to me is supporting and protecting people from harm, abuse or neglect, for instance a fall, or when a service user calls, we should be attending to their needs. I have never seen any concerns but would talk to the senior or manager if I had concerns.” The manager and deputy manager knew what to record and actions to take to keep people safe.

The provider did not always work well 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 completed and staff had information to support people at risk of falls and skin damage and to manage specific health conditions. People’s plans showed staff sought support from external health professionals to manage those risks. People felt safe when staff supported them with known risks. One person said, “I need a hoist to get me up. I got up yesterday, they will get me up today. They don’t hurt me when they hoist me, there’s 2 carers.”

Overall, we saw some improvements, but further work was required in how staff recorded their actions to monitor and manage potential risks. For example, staff used record charts when people had an identified need which required monitoring, for example, food and fluids. In some cases, the manager and deputy manager were unable to advise why monitoring of food or fluids had been implemented. We were not assured the manager or deputy understood when or why people required close monitoring. When we asked why, the manager said, “I don’t know.”

Ongoing monitoring had become confusing for staff because the provider was using 2 systems for recording, 1 paper based and an electronic system. Both methods consistently contradicted each other for those people we reviewed. Daily fluid targets were generic and not always specific to people’s individual needs. Where people did not consume their target intake, there was limited or no evidence of what the next steps were or how people were to be encouraged. We continued to find the quality of recording lacked specific and important information, such as what people liked, the portion size they had been offered and what they had actually consumed. In 1 example, on the 21 April 2025 the electronic records recorded 1 person had drunk 485mls and paper records showed they drank 225mls. There was no effective system to reconcile paper and electronic monitoring charts. On 6 days between the 21 April to 30 April 2025, records demonstrated the person had drunk less than 600mls of fluids against their target intake of 1500mls. Some of the staff recordings were not always legible and a total count of fluids was not always completed so it was unclear what people had drunk. The manager had not reviewed these records on a regular basis to ensure they had been completed correctly to reflect all the care people had received, despite this being an issue at the last assessment. We were not always assured people’s hydration needs were always met.

We found similar issues for people who required a specialist diet. Some people’s records recorded different food consistencies to what they had been assessed as. We were assured people received the meal at the right consistency, but the records were not reflecting this. Staff shared examples of known risks to people living at the service and they knew how to care for people, for example when people became distressed and required emotional support. Staff told us risk assessments were in place including actions on how to manage those risks such as regular checks on people to ensure they were safe. One staff member told us a person had a fall, following their fall it was agreed hourly checks were made on the person to monitor their safety.

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 felt safe, were pleased with their personal space and were able to navigate all areas of the home. People said they were supported by staff with the right equipment to keep them as safe as possible. We found some improvements to the environment had been made following our last visit. However, we continued to find issues with the fire doors which could impact on their effectiveness in the event of an emergency. We found 4-bedroom doors and a communal lounge door either did not shut properly or shut too fast. In the event of an emergency and these doors closed quickly, there was potential for people to be harmed. If a fire door closes too slowly it significantly compromises its ability to contain a fire and smoke, putting people at risk and potentially leading to a more severe fire.We saw regular fire door safety checks had been completed but they recorded no issues. A regional estates staff member told us their checks did not cover whether fire doors shut too fast or too slow.

We discussed this with the manager, but they were not aware of the specific doors we identified with issues, despite them completing checks and identifying other fire doors that required attention. Staff told us they had been trained how to respond in the event of a fire. Staff said the evacuation procedure had been practiced. Staff shared they had a ‘Fire Marshall’ come to the home to show them how to use certain equipment such as a fire extinguisher. The manager told us and showed us that actions were taken to redecorate and improve bedrooms when they became vacant.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Most people and relatives were complimentary of the staff, their skills and approach to caring for them. One person said, “It’s hard to say, there is enough carers (staff) to look after me. The carers are very experienced. They answer my bell in five minutes usually.” Another person said, “There are enough staff, I have never seen inadequate staffing.” A relative told us they felt staffing levels at weekends were less than usual. We found 2 people were not convinced staffing levels were good for them. One person said whilst the staff were nice, they were not always available to support them when they required support such as when they would like to be assisted with their personal care. This meant their personal care needs were not met until midday or later.

Most of the staff felt staffing levels made it difficult for them to spend extra time with people. One staff member said, “Our residents have high needs and not many people are mobile, and they need assistance. There are a few people who need emotional support, so when we are trying to do care we have to come out of care to support other people who may need help. We are quite stressed. It’s a nice place to work but we have been getting residents with higher needs.” Staff told us they continually prioritised what was important and supported those people when they needed it. Staff said at times, they had to explain to people they would be back to help them. The manager told us they reviewed staffing levels based on people’s assessed needs and whenever new people moved into the home, staffing levels were reassessed. We found on both days of our visit, 2 of the 4 care staff went on breaks together meaning staff on other floors had to cover. Staff said on occasions, this meant they could not help everyone, especially if people needed more than 1 staff member to assist them. We observed some people being supported with activities however, most people remained in their rooms. One person told us they wanted to be outside in the garden however, they were unable to go out until they had been supported with personal care. During our second day of inspection, we saw more people were accessing the garden area however, personal care was still being completed until midday/early afternoon. We discussed this with the manager to understand who managed and had direct oversight of the shift. The manager said they would look into the deployment of staff at key times to ensure staffing levels continued to meet people’s needs. Where staff had supernumerary time for specific tasks, this was not always protected so when care provision was prioritised, this had some impact on other tasks being completed. For example, updating of electronic care plans.

The provider operated safe recruitment processes. Safe recruitment checks Included undertaking checks such as references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer.

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. People and relatives were pleased with the cleanliness of the home. A typical comment was, “My room is always cleaned every day. No odours ever.”

The provider assessed and managed the risk of infection. The home was clean and tidy with no unpleasant odours and staff followed good infection control and food hygiene practices. The provider had processes to share information about any infectious outbreaks in the home to mitigate the risks of the infection spreading. Our observations showed personal protective equipment was available and accessible and staff wore it at the right times. There was signage around the home reminding staff and visitors about good hand hygiene and the correct use of personal protective equipment. Paper towels in bathrooms and regular emptying of bins helped reduce the risk of cross contamination.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

People’s preferences of how they liked to take their medicines was followed. People received their medicines from staff who were assessed as competent and had completed training in the safe handling and administration of medicines. People’s records clearly stated if people had any allergies, reducing the chance of someone receiving a medicine they were allergic to. Medicines were stored correctly and at the right temperatures, however staff recorded temperatures of the medicines fridge and medicines room in the wrong section of the form. Staff carried out regular medicine audits however, the audits failed to identify this issue. When doing medicine stock checks, we noticed a person who recently had the dose of a pain medicine (tramadol) reduced from ‘three times a day’ to ‘twice a day’ by the doctor. However, the box with the ‘three times a day’ dose had not been removed from the stock in use. This could have led to an error in administration if a staff member was unaware of the new dose change. Care plans had medicine information built into them however, they did not always contain enough information to allow staff to manage people with complex medical conditions such as diabetes. We saw a care plan for a person that contained no information on how to manage high blood sugar other than to monitor. This person was seen to have a very high blood sugar reading recorded but this was not properly managed. This was not re-checked until the following day which does not follow national guidelines.

When required (PRN) protocols were in place however, they did not always include clear guidance on how to assess the effectiveness of the medicine or the next steps to take based on the outcome. This lack of detail increased the risk of inconsistent care and made it difficult for staff to make informed decisions. Where medicines were given covertly (disguised in food or drink), up-to-date guidance was not available from the pharmacist on how medicines should be administered safely. There was no evidence of regular reviews on best interest meetings as the named home representative dated January 2024 no longer worked at the service. In addition, regular reviews of mental capacity in relation to covert medicines were not recorded so we could not be assured they were happening.