The Beeches Nursing and Residential Care Home

The Beeches Nursing and Residential Care Home is a residential care home providing personal and nursing care to up to 31 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 20 people using the service.

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

Infection prevention and control practices were followed. The home was clean and tidy throughout. Some staff did not wear face masks correctly, which the registered manager addressed straightaway.

Medicines were managed safely. Potential safeguarding issues were referred to the local authority and investigated. Where required, risk assessments were carried out and measures identified to reduce risks.

There were sufficient staff to meet people’s needs and new staff were recruited safely. Incidents and accidents were investigated and analysed to identify areas for improvement.

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.

People, relatives and staff gave positive feedback about management of the home and confirmed the registered manager was approachable. The provider had a structured approach to quality assurance.

Although people, relatives and staff had opportunities to provide feedback, the frequency of formal consultation could be improved. We have made a recommendation about this.

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 6 January 2021).

Why we inspected

We received concerns in relation to responding to people’s needs and the quality of care provided. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Beeches Nursing and Residential 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.

The Beeches Nursing and Residential Home was providing personal and nursing care to 16 people aged 65 and over at the time of the inspection. The service can support up to 31 people.

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

People were kept safe in the service by staff who understood personal risks and what they needed to do to prevent accidents and incidents. Medicines were managed in a safe manner by staff who were assessed as competent to do so. Regular checks were carried out on the home including fire detection equipment.

Hand-washing facilities were available, and visitors had their temperatures taken and completed

track and trace device information before entering the service. Personal protective equipment (PPE) was available throughout the service. Relatives confirmed people were safe in the home.

People were supplied with nutritious food which met their dietary needs. Staff worked with other agencies to enhance people’s health and wellbeing.

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.

The registered manager had returned to the service and was working to change the culture of the staff team. They had made improvements to the delivery of the service and recruited new staff to promote improvements. Quality audits carried out by the registered manager showed they had noted good quality care and identified further areas for improvement.

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 requires improvement (report published 7 June 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about safety in the home. A decision was made for us to inspect and examine those risks. This inspection was also carried out to follow up on action we told the provider to take at the last inspection.

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 coronavirus and other infection outbreaks effectively.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous five key questions inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last inspection, by selecting the ‘all reports’ link for The Beeches Nursing and Residential Care on our website at www.cqc.org.uk

The Beeches Nursing and Residential Care Home is registered to provide personal and nursing care for up to 31 people. Care is primarily provided for older people and older people living with a dementia. At the time of the inspection there were 17 people using the service.

The service can accommodate people over two floors. There are communal lounge, dining areas and bathing facilities. At the time of the inspection the first floor of the service was unoccupied.

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

At this inspection improvements had been made in relation to risk. However, further work was needed. The provider continued to be in breach of regulation 12.

This inspection identified improvement had been made in relation to safety. However, the fire authority had visited and identified a number of actions needed to ensure fire safety. At the time of the inspection there was work still ongoing with fire safety.

Since our last comprehensive and focussed inspection of the service we found there had been improvements made with the safe management of medicines. However, further work was needed to update the providers policy and practice in relation to the management of medicines to incorporate current best practice.

We have made a recommendation about updating the policy and practice.

Accidents and incidents were recorded and analysed, and risk assessments were in place. The manager and staff understood their responsibilities about safeguarding.

There were enough staff employed and on duty at any one time to meet the needs of people. The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.

Staff had the skills and knowledge to deliver care and support in a person-centred way. People were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible; the policies and systems in the service did support this practice. At the time of the inspection, work was ongoing to strengthen the providers documentation related to mental capacity and to ensure that records evidenced how staff were following the principles of the Mental Capacity Act 2005.

People told us their privacy and dignity was respected and their independence encouraged. People and relatives were positive about the caring nature of staff and the service they received. People were able to participate in a range of activities if they chose to do so.

The management team were open and approachable which enabled people and relatives to share their views and raise concerns. People told us if they were worried about anything they would be comfortable to talk with staff or the manager.

The provider monitored quality, acted quickly when change was required, sought people's views and planned ongoing improvements.

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) At the last comprehensive inspection we rated the service as inadequate, (published November 2018). We found multiple breaches of the regulations. We took urgent enforcement action and placed conditions upon the provider's registration, including the suspension of admissions.

Exiting special measures

This service has been in Special Measures. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Previous breaches

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made. However, the provider is still in breach of one regulation.

Why we inspected

This inspection was carried out to follow up action we told the provider to take at the last inspection.

We have identified a breach in relation to fire safety at this inspection.

Follow up

We will request an action plan from the provider detailing the action they will take to ensure fire safety. We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

The Beeches Nursing and Residential Care Home 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. The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. At the time of the inspection there were 20 people who used the service.

At our last comprehensive inspection of The Beeches Nursing and Residential Care Home on 13 and 22 August 2018 we found evidence that people who used the service were at risk of significant harm. We found breaches in seven regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The inspection identified that people did not receive safe care and treatment. We found serious concerns with the management of medicines. Risks for people who used the service were not always adequately assessed to ensure people were safe. We found areas of the service to be unclean and infection control was poor. The passenger lift had not had a thorough examination as required under the Lifting Operations and Lifting Equipment Regulations (LOLER). The arrangements for fire safety were inadequate. At times there were insufficient staff to meet the needs of people who used the service and this had resulted in people’s care being compromised. Profiles were not available for all agency staff who worked at the service. This meant the provider could not be sure agency staff were suitably qualified and had the clinical skills to support people and to confirm they were of good character.

At the inspection on 13 and 22 August 2018 we also found that staff had not received supervision on a regular basis. The standards within the induction programme provided at the service were not aligned with the standards in the Care Certificate. The Care Certificate is an agreed set of standards that sets out the knowledge, skills and behaviours expected of specific job roles in social care. There were no records to confirm agency staff had received an induction in relation to people who used the service, expectations and safe working practices. We found that the provider was in breach of regulation in relation to consent because the Mental Capacity Act (2005) guidelines were not always followed. Many bedrooms and communal areas in need of redecoration and refurbishment. There was insufficient monitoring and oversight of people’s nutrition and hydration. People were not always treated with dignity and respect. Staff failed to ensure people’s needs were met and this compromised their dignity. Care records were insufficiently detailed to ensure the care and treatment needs of people were met. Activities and outings were limited and particularly for those people living with a dementia. Quality monitoring of the service was ineffective as it had not identified the concerns that we had found at the inspection. We rated the service as inadequate.

Due to our concerns we served a Notice of Decision to restrict admissions to the service without prior agreement of the Care Quality Commission.

We carried out this focussed inspection of the service on 1 October 2018 to determine if any improvements had been made in relation to safe care and treatment. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Beeches Nursing and Residential Care Home on our website at www.cqc.org.uk. The inspection highlighted some improvement. However, we did identify a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the time of the inspection the registered manager was absent from the home. However, the deputy manager had stepped up and was acting as 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.

We found serious concerns with the management of medicines. The recording of medicines was not accurate and specific guidance to support staff with the administration of medicines was not always available. We found gaps in the recording of the temperatures of the medicine fridge. In addition, the temperature of the room in which medicines were stored was too high. This meant the quality of medicines may have been compromised. One person was prescribed pain relieving medicines to be applied as a patch. This patch should be changed every seven days to ensure a continuity of pain relieving medicines. However, records indicated that this person had gone longer than seven days. Documentation relating to the application of creams was confusing.

Risks for people who used the service were not always adequately assessed to ensure people were safe and where possible, actions identified for staff to take to mitigate these events occurring.

We found the cleanliness and infection control to be much improved. Many carpets had been replaced and communal areas and bathrooms were cleaner. Some furniture had been replaced.

We found fridges and freezers to be cleaner with food stored correctly. However, the meat only fridge was found to have dirty seal and we did find some out of date ham within the fridge. We immediately reported this to the manager who removed this.

There continued to be concerns in relation to safety as we found doors to the laundry and kitchen were closed but not locked. Some people were living with a dementia and would not understand the possible consequences if they were to go into the laundry and kitchen.

The manager told us problems with the heating and hot water had been rectified. However, we found the water from some hot taps was cool.

At our last comprehensive inspection of The Beeches Nursing and Residential Care Home on 8, 15 and 22 November 2017 we found evidence that people who used the service were at risk of significant harm. We found breaches in five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The inspection in November 2017 identified that people did not receive safe care and treatment. Staffing levels and the deployment of staff did not ensure people's care needs were met. Recruitment procedures were not robust. Risks to people were not appropriately assessed and managed. We found serious concerns with the management of medicines. The premises and equipment were not clean and properly maintained. Infection control was poor and people had not been protected from environmental risks. Emergency evacuation plans were not available for all people. The certificate to confirm that there had been professional testing of the electrical systems, circuits and any other service carrying electricity around the building was not available. The building was not suitably heated and environmental risks were not managed. We rated the service as inadequate.

We carried out a focussed inspection of the service on 20 March 2018 to determine if any improvements had been made. The inspection highlighted some improvement. However, Inspectors did identify breaches in Regulation 11: Need for Consent and Regulation 12: Safe Care we identified two breaches in regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found further work was needed to ensure mental capacity assessments were decision specific and we found that best interest decisions were not recorded in care plans. Improvements were needed in bathrooms and in the cleanliness of the service. We rated the service as Requires Improvement.

Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all five key questions to at least Good.

At this inspection of the service on 13 and 22 August 2018 we found the service had deteriorated and rated the service as Inadequate. We found the provider had failed to follow their action plan. We identified significant shortfalls in the quality of the care people were receiving and we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Due to our concerns we served a Notice of Decision to restrict admissions to the service without prior agreement of the Care Quality Commission.

The Beeches Nursing and Residential Care Home 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. The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. At the time of the inspection there were 20 people who used the service.

At the time of the inspection the registered manager was absent from the home. However, the deputy manager had stepped up and was acting as 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.

During our inspections in November 2017 and March 2018 we found that the home was in breach in relation to safe care and treatment. At this inspection we looked to see if the required improvements had been made. We found this breach in regulation had not been met.

We found serious concerns with the management of medicines. The recording of medicines was not accurate and specific guidance to support staff with the administration of medicines was not always available. We found gaps in the recording of the temperatures of the medicine fridge. In addition, fridge and treatment room temperatures were too high. This meant the quality of medicines may have been compromised.

Risks for people who used the service were not always adequately assessed to ensure people were safe and where possible, actions identified for staff to take to mitigate the risks occurring.

We found areas of the service to be unclean and infection control was poor. We found stained carpets, stained and dirty bed linen, unclean bathrooms and dirty toilet brushes. The laundry room needed refurbishment. In addition, staff frequently left the laundry door open which meant people could access the laundry and come to harm. Some people were living with a dementia and would not understand the possible consequences if they were to go into the laundry.

Fridges and freezers were dirty both on the seals and internally. We found that raw meat was not stored correctly in the fridge. It's important to store meat safely to stop bacteria from spreading and to avoid food poisoning. We reported our concerns to environmental health.

The passenger lift had not had a thorough examination as required under the Lifting Operations and Lifting Equipment Regulations (LOLER). This is a legal obligation to ensure a competent person, independent of the company responsible for servicing or preventative maintenance, carry out a LOLER inspection twice yearly. During the inspection the passenger lift was taken out of action until the appropriate safety tests had been undertaken. We reported our concerns to the Health and Safety Executive.

The arrangements for Fire safety were inadequate. A representative from County Durham and Darlington Fire and Rescue Authority visited the service on 28 August 2018 and found non-compliance with fire regulations. We have been informed by the representative of the fire authority that they will continue to monitor progress to the areas of concern.

At times there were insufficient staff to meet the needs of people who used the service and this had resulted in people’s care being compromised.

Checks were made before new staff started work to make sure they were of good character and safe to work with people. However, we did find that profiles were not available for all agency staff who worked at the service. This meant the provider could not be sure agency staff were suitably qualified and had the clinical skills to support people and to confirm they were of good character.

Staff had received supervision on an irregular basis and not in line with the providers policy which was a minimum of five supervision sessions a year. Training and annual appraisals of staff were not up to date.

The standards within the induction programme provided at the service were not aligned with the standards in the Care Certificate. The care certificate is an agreed set of standards that sets out the knowledge, skills and behaviours expected of specific job roles in social care. There were no records to confirm agency staff had received an induction in relation to people who used the service, expectations and safe working practices.

During our inspections in November 2017 and March 2018 we found that the home was in breach in relation to consent because the Mental Capacity Act (2005) guidelines were not always followed. At this inspection we looked to see if the required improvements had been made. We found this breach in regulation had not been met.

During the inspection we walked around the service and found many bedrooms and communal areas in need of redecoration and refurbishment, particularly on the ground floor. The carpet in the main lounge and downstairs corridor was stained. The service was not dementia friendly, signage was poor and there was no cohesion in the design, theme or colour scheme. Repairs to the service were needed internally and externally.

There was insufficient monitoring and oversight of people’s nutrition and hydration. In addition, staff failed to make a timely referral to an occupational therapist for one person who used the service for an assessment for a suitable chair. As this person was assessed as being unsafe to sit in an ordinary chair they were being cared for in bed until the assessment had been carried out.

People told us they were happy with the quality and variety of meals offered.

People were not always treated with dignity and respect. Staff failed to ensure people’s needs were met and this compromised their dignity. After lunchtime we found some people to have clothes stained with food, but staff did not support people to change their clothes. Some people who used the service had dirty finger nails.

Care records were insufficiently detailed to ensure the care and treatment needs of people were met. Care plans were brief and task based, with less specific information to guide staff.

Activities and outings were limited and particularly for those people living with a dementia.

Quality monitoring of the service was ineffective as it had not identified the concerns that we had found at the inspection. The provider had not obtained adequate feedback from people to monitor and improve the quality of care and service provided.

Staff were aware of the different types of abuse and were confident senior staff would take the appropriate action in respect of this.

People and relatives told us that staff were caring, kind and considerate.

People and their relatives told us they would raise any concerns they had with staff or the manager and were confident these concerns would be dealt with.

Staff during discussion. demonstrated a passion about the service and their support of the manager. They

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk”

The Beeches Nursing and Residential Care Home 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. The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. At the time of the inspection there were 17 people who used the service.

At the inspection of the service in November 2017 we rated the service as Inadequate. People did not receive safe care and treatment. Staffing levels and the deployment of staff did not ensure people's care needs were met. Recruitment procedures were not robust. Risks to people were not appropriately assessed and managed. We found serious concerns with the management of medicines. The provider was not ensuring the premises and equipment were clean and properly maintained. Infection control was poor. The provider had not protected people from environmental risks.

Emergency evacuation plans were not available for all people. The certificate to confirm that there had been professional testing of the electrical systems, circuits and any other service carrying electricity around the building was not available. The building was not suitably heated and environmental risks were not managed.

Staff were not up to date with their training and induction records were incomplete. There were insufficient nurses with the right clinical skills to care for people. Appropriate checks had not been made to confirm all bank and agency nurses were suitably trained with the right clinical skills. Nurses employed at the service had not received clinical supervision and the registered manager had not received supervision and an annual appraisal.

Care plans were insufficiently detailed to ensure the care and treatment needs of people who used the service were met. Care plans were not reviewed and updated on a regular basis. Mental capacity assessments and best interests were not available within care plans. Systems and processes for monitoring the quality of the service provision were poor.

Since our last inspection of the service the Care Quality Commission has continued to monitor the service. We also shared our concerns with commissioners. In light of the serious concerns, executive strategy meetings were set up and chaired by a senior manager of Durham County Council and CQC attended some of these meetings. These meetings have been on-going as a result of the serious concerns we identified. Throughout this time, representatives from Durham County Council and the Clinical Commissioning Group have visited the service to provide support and advice to the registered manager and staff.

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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection on 20 March 2018 we found improvements had been made and rated the service as Requires Improvement.

Although improvements had been made further work was needed. When we arrived at the service we walked around to check on cleanliness and infection control. We found the home to be clean with minor areas for improvement. In addition we identified that some pillows were in need of replacement and work was still needed in the ground floor shower.

For people who did not always have capacity, staff had not completed mental capacity or best interest assessments for areas such as choices about healthcare, personal care, medicines and equipment to be used.

The home was warm and issues with the heating had been addressed. Areas of the home where it may be dangerous for people living at the service to access were locked. Emergency evacuation plans for people who used the service were readily available near the main entrance of the service and provided staff with the information they needed to support people in the event of an emergency situation.

We checked staff recruitment records and found pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with people. The registered manager had obtained profiles for all agency nurses to confirm they were suitable. However, we did note that the service was using agency mental health nurses to cover some shifts, but their profile did not detail if they had up to date clinical experience. We pointed this out to the registered manager at the time of our inspection who told us they would contact the agency to ensure agency nurses had the clinical skills needed.

After our inspection visit in November 2017, the provider increased staffing levels to ensure there were sufficient staff on duty to meet people’s needs. The provider voluntarily agreed not to admit any more people until action had been taken to address all of our concerns raised at the inspection. People, relatives and staff told us there were enough staff on duty.

Records were available to confirm professional testing of the buildings electrical systems had been completed and we were provided with evidence that work required as the result of this testing had been completed.

Risks were assessed to ensure people were safe and where possible, actions were identified for staff to take to mitigate these occurring. Systems were in place to ensure that medicines had been ordered, received, stored, administered and disposed of appropriately. Staff recorded the temperature of the room and fridge in which medicines were stored. We noted that on occasions the temperature of the room and fridge were too warm.

Most training was up to date. The registered manager told us that courses had been arranged throughout May 2018 to meet any gaps in training. Records were available to confirm that bank or agency staff now received an induction. Nurses told us they had received clinical training in venepuncture, male and female catheterisation, the use of syringe drivers and PEG feeding. A syringe driver is used to administer a steady flow of injected medicine continuously under the skin. PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medicines to be put directly into the stomach, bypassing the mouth. Staff spoke positively about this training.

Nursing staff told us the supported each other. They told us they had group meetings and informal chats but not had formally documented these clinical supervision sessions. The deputy manager told us they were to take responsibility of clinical supervision and would be formally planning these sessions and making a record of them.

Care plans contained person centred information on people’s support needs and reinforced the need to involve people in decisions about their care and to promote their independence. However, fluid intake charts were inconsistently completed and fluid intake goals and totals were not recorded.

We found that systems and processes for monitoring the quality of the service provision had improved. Regular audits including infection, prevention and control and health and safety had been undertaken which highlighted where improvements were needed.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.

The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. On the first day of the inspection there were 23 people who used the service, reducing to 18 people on day three of the inspection.

This inspection took place on 8, 15 and 22 November 2017. The inspection was unannounced (all of the inspection days), which meant that the staff and provider did not know we would be visiting.

At our last comprehensive inspection in September 2015 we rated the service as Good. However, we found a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at that time, as the provider was not always maintaining an accurate, complete and contemporaneous record in respect of each person who used the service as some care records had not been updated or evaluated for several months. We revisited the service in June 2016 to check if improvements had been made and found that action had been taken to address the breach.

At this inspection of the service in November 2017 we rated the service as Inadequate.

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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People did not receive safe care and treatment. Staffing levels and the deployment of staff did not ensure people's care needs were met. Staffing levels were not effectively monitored. We spoke with the provider after the first day of the inspection who agreed to increase staffing levels. Recruitment procedures were not robust to ensure those staff working with people who used the service were suitable to do so.

Risks to people were not appropriately assessed and managed. The provider was not ensuring that people who had behaviour that challenged were appropriately supported, and that incidents were analysed, which exposed them as individuals, and other people, to the risk of harm.

We looked at the arrangements in place for the management, storage, recording and administration of medicines and found serious concerns with the management of medicines. There were unexplained gaps in people’s medicine administration records (MAR) which records when people are given their medicines. There were no records for those medicines prescribed to be applied to the body in a patch (for example for pain relief) to confirm where and when the patch had been applied to different areas of the back, upper arm or chest. Medicines prescribed as a patch should be rotated to avoid applying to the same area for 14 days. Some people had not received their medicines as these had been out of stock. People had not always received their medicines at the time they were prescribed.

The provider was not ensuring the premises and equipment were clean and properly maintained. Infection control was poor. We found toilets stained with faeces and furniture, walls, sinks, carpets and floors which were dirty and stained. The service had a malodour and many of the carpets were worn and dirty. We pointed this out to the registered manager and provider at the time of the inspection and they took some action to address our concerns, however further work was needed.

The provider did not protect people from environmental risks. Throughout the inspection we found concerns with premises safety. We found the medicine room unlocked. There were unlocked doors leading to a boiler room and another door which then led to a door where access to the grounds of the home was possible. The sluice room on the first floor of the service was not locked. There was an unlocked room on the first floor of the service used as storage which led to the oil boiler.

The fire authority visited the service on 15 November 2017 and found non-compliance with fire regulations highlighting major deficiencies. The provider was not ensuring that suitable fire safety and emergency arrangements were in place. The emergency evacuation plans were not available for all people who used the service or readily available to emergency services in the event of an emergency. We contacted the fire authority after our inspection who informed us they had visited again on 8 December and were satisfied the major deficiencies had been resolved. They also told us improvement into resolving minor deficiencies was well underway.

The certificate to confirm that there had been professional testing of the electrical systems, circuits and any other service carrying electricity around the building was not available. The building was not suitably heated and environmental risks were not managed.

Examination of records and discussion with staff identified staff were not up to date with their training and induction records were incomplete. There were insufficient nurses with the right clinical skills to care for current and potential people who were to use the service. Appropriate checks had not been made to confirm all bank and agency nurses were suitably trained with the right clinical skills to care for people who used the service.

Nurses employed at the service had not received clinical supervision and the registered manager had not received supervision and an annual appraisal.

We looked at care plans of people who had been identified as lacking in capacity to make an informed decision. We found they had mental capacity assessments for care and accommodation; however, staff were making other decisions for health, personal care and continence care without capacity assessments or best interest decisions being undertaken. Care plans were insufficiently detailed to ensure the care and treatment needs of people who used the service were met. Care plans were not reviewed and updated on a regular basis.

Systems and processes for monitoring the quality of the service provision were poor. The provider had not ensured that appropriate governance structures, systems and processes such as audits were in place. This failure to appropriately audit the operation of the service resulted in the provider not identifying the shortfalls that we identified during our inspection.

Staff knew how to identify signs of abuse and understood the procedure they needed to follow if they suspected abuse might be taking place.

The handyman had carried out some safety checks of the building and service, however, we did note there were still some cold water coming from hot taps. In addition, we found sinks in other areas had hot taps that were reading low temperatures.

Staff were aware of their responsibilities to raise concerns about people’s care and to record accidents. A monthly accident audit was completed. The registered manager told us that lessons were learnt when they reviewed all accidents to determine any themes or trends.

People were supported to eat and drink in sufficient quantities to remain healthy. Feedback about the quality of meals was mixed. Special diets were catered for, and alternative choices were offered to people if they did not like any of the menu choices. Examination of records informed that some people had lost weight and some people had not been weighed on a regular basis.

We observed examples of when staff were kind, caring and courteous. In general privacy and dignity of people was promoted and maintained by staff. Explanations and reassurance was provided to people throughout the day.

Staff encouraged people to actively participate in recreational activities that reflected their social interests and to maintain relationships with people that mattered to them. There were limited activities available for those people living with a dementia. The service had a clear process for handling complaints.

The registered manager was aware of the Accessible Information Standard that was introduced in 2016. This standard aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand. They told us they provided and accessed information for people that was understandable to them. The registered manager and staff had worked with speech and language therapists who had developed communication books to assist and improve communication, especially for those people living with a dementia.

The overall rating for this service is Inadequate and the service is therefore in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take actio

The Beeches Nursing and Residential Care Home provides care and accommodation for up to 31 people who require nursing or personal care. On the day of our inspection there were 16 people using the service.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 the last unannounced, comprehensive inspection on 23 and 24 September 2015, we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Beeches Nursing and Residential Care Home on our website at www.cqc.org.uk.

This focused inspection took place to follow up the breach relating to the service was not always maintaining an accurate, complete and contemporaneous record in respect of each service user.

After the comprehensive inspection on 23 and 24 September 2015, we asked the provider to take action to make improvements. The provider wrote to us to say what they would do to meet legal requirements in relation to this breach. We undertook this focused inspection to check that the registered provider had followed their action plan and had made improvements at the service.

We found improvements had been made in the way the home maintained an accurate, complete and contemporaneous record in respect of each service user.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives and the staff supporting them, and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

During our visit to The Beeches, we checked the premises and found it provided a safe, suitable and clean environment.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We discussed DoLS with the manager, who told us that she was aware of the impact of the recent supreme court decision about how to judge whether a person might be deprived of their liberty and had been in contact with the local authority to request clarification before submitting applications.

We saw copies of mental capacity assessments in people's care records and where people had been found to lack the capacity to make a decision, best interest decisions had been made.

Before anyone received care from the service, pre-admission information was obtained and assessments of people's individual needs took place. This meant the staff knew how to care for the people who used the service.

The manager set the staff rotas and took people's care needs into account when making decisions about the number of staff required. We saw that there were sufficient numbers of staff on duty in order to meet the needs of people using the service.

Is the service effective?

Each person had individual support plans which set out their specific care needs and people and their family members had been involved in the assessment and planning of their care.

We found that there were clear processes for obtaining people's consent and ensuring people could make informed decisions where appropriate.

Staff we spoke with were knowledgeable about the people who used the service and could describe to us their individual needs and likes.

Is the service caring?

People's needs were assessed and care and treatment was planned and delivered in line with their individual support plan.

We observed staff supporting people in a caring and sensitive way.

People told us they were happy with their care. They told us, 'I like it here', 'it's a happy place', 'I like it that people mix' and 'it's the best place I've been in.'

Is the service responsive?

People were asked for their views on a regular basis. A family member told us 'I've always been able to approach the manager. They've always said come and see me any time.'

Records showed that people's needs had been taken into account and care and support had been provided in accordance with people's wishes.

Family members we spoke with said they were satisfied with their relative's care and were aware of how to make a complaint. They did not raise any complaints or concerns with us about their relative's care.

Is the service well-led?

The home had a manager who was not registered with CQC. The manager told us she was in the process of submitting her application.

We saw that a quality assurance plan was in place, which included a list of audits to be carried out each month however the last recorded audit was in April 2014. No audits had been carried out during the manager's recent maternity leave.

The manager told us that the provider made regular visits to the home however none of these visits were recorded. This meant the provider was unable to provide evidence that regular audits were undertaken to gather information about the safety and quality of their service.

We saw that staff were supported by the management team at the home to do their jobs properly.

Audits had been carried out in areas such as care documentation, accidents that had occurred in the home and the dependency levels of the client group. We saw that effective systems were in place to assess and monitor the quality of service that people received.

We saw that complaints are dealt with according to the home's policy and procedures and when people had raised concerns they were dealt with promptly by the manager.