Beddoe Court

Updated 18 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection consisted of 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Craighaven is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Craighaven is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 10 members of staff including the registered manager, deputy manager, provider’s representative, senior care worker, care staff and 1 health professional. We also spoke with 6 people and 10 relatives for feedback on their experiences of care. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed 5 people’s care records and 3 people’s medicine administration records. A variety of documentation relating to the management of the service including recruitment files, policies, procedures, audits and quality surveys were also reviewed.

Updated 18 March 2023

About the service

Craighaven Care Home is a residential care home providing personal care to 27 people at the time of the inspection. The service can support up to 35 people, including older people and those living with dementia.

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

Risks to people’s health and safety were not always robustly assessed and used to develop effective risk management plans. Recent changes in management and a move to electronic care management systems meant some governance systems were not in place or operating effectively to monitor and improve safety and quality in care.

Staff received safeguarding training to help them identify potential signs of abuse, and when to report potential safeguarding concerns. There were enough staff to provide safe care, and feedback received from staff about staffing levels was positive. Medicines were ordered, stored and administered safely. We assured by the infection prevention and control practices. Accidents and incidents were recorded and analysed for trends or patterns.

Assessments were carried out prior to people moving to Craighaven Care Home to ensure the service could meet their needs safely. Staff received an induction and training relevant to their roles and understood how to care for people effectively. People were encouraged to eat and drink enough to maintain a balanced diet and overall, people gave positive feedback about the food provided. Staff worked closely with external health professionals in response to changes or concerns regarding people’s health and well-being. Signage helped to orientate people to their surroundings, and people’s bedrooms were personalised.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There was a positive culture which was echoed in feedback from staff and relatives. People and relatives spoke positively about the leadership of the home. When important events and incidents occurred in the home, the registered manager understood their responsibilities to tell us, CQC, and inform people’s relatives. Annual surveys were used to gather feedback from relatives to help identify and plan for improvements. The service worked in partnership with external health professionals to improve people’s outcomes.

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 8 August 2019).

Why we inspected

We received concerns about managing risks to people’s safety, access to medicines, staffing and care quality. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

In response to our inspection the provider took immediate action to address the shortfalls and ensure risks to people were assessed and managed.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Craighaven Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.