Archived: Beacon Edge Care Home

Updated 17 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 21, 22 November and 13 December 2016 and was unannounced.

The inspection was undertaken by two adult social care inspectors, a pharmacist inspector 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.

Prior to the inspection we looked at the information we held about the service for example notifications, comments from relatives of people who used the service and from health and social care professionals.

Before the inspection the interim manager, at that time, completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We spoke with 13 people who lived at the home and ten of their relatives, friends or visitors. We spoke with three of the registered nurses, three care staff, the activities co-ordinator and receptionist. We also spent time talking to the interim manager, at the time of our inspection, and the regional support manager. We spoke via telephone with the area training manager in order to obtain some clarity regarding aspects of staff training. We spoke to health and social care professionals order to get their views of the service.

We spent time in communal areas of the home observing staff working and supporting some of the people who used the service.

We looked in detail at the care records of five people who lived at the home. We looked in detail at the medicines; medication administration records (MARs) and other records of 17 people who lived at Beacon Edge Care Home.

We reviewed two staff recruitment records and looked at the staff training and supervision records.

We also looked at some of the records regarding the running of the home, such as quality audits, action plans, meeting minutes and the ‘Residents Report 2015’ (a resident satisfaction survey carried out by the provider).

Updated 17 November 2017

The inspection took place on 21, 22 November and 13 December 2016. The inspection was unannounced.

At our last inspection of Beacon Edge Care Home, the service was compliant with the Regulations in force at that time. However, we did make some recommendations for improvements in relation to staffing levels and the safe management of medicines (particularly creams/ointments).

During our inspection in November 2016, we found that the recommendations for improvements had not been actioned by the provider.

Beacon Edge Care Home provides care and support (with nursing) for up to 33 people who live with dementia. Accommodation is provided in single bedrooms all on the ground floor of the home. There are communal lounge and dining areas. The home is located in the town of Penrith and is set in its own grounds with ample parking.

The service should have a registered manager in post. At the time of our inspection the service did not have 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were not always enough staff available to meet the needs of people who used this service and sometimes people had to wait for help. We observed some good interactions and friendly banter between staff, visitors and people who used the service. Staff did not consistently use this approach and this was particularly noticeable when they were supporting people with eating and drinking or where people had limited verbal communication skills.

Care plans and risk assessments had not been developed to meet the individual needs of people who used this service. Staff did not always know what had been written in care plans and daily notes. We observed that much of the support provided by staff was ‘task orientated’ rather than centred on people’s individual preferences. We have made a recommendation that the service finds out more about training for staff, based on current best practice, in relation to supporting the specialist needs of people living with dementia.

We observed some social activities taking place at the home during our inspection. These were limited to communal areas, meaning that people being looked after in bed were placed at risk of social isolation. Beacon Edge Care Home provided care for people living with dementia, but there was little evidence to show that activities and the environment took this condition into account. We have made a recommendation that the service finds out more about the environmental design of the premises in relation to the specialist needs of people with dementia.

The people we spoke to during our inspection thought that the frontline staff were caring, pleasant and helpful. Visitors told us that staff kept them up to date with any concerns there might be regarding their relatives. We did not see any signs of people feeling uncomfortable around staff.

Medicines were poorly managed and people were placed at risk of not receiving their medicines as prescribed.

People who used the service had not always been supported appropriately with eating and drinking. Special dietary requirements were poorly managed. However, we noted that when concerns had been identified advice had been obtained from the dietician or speech and language therapist.

There were gaps in the staff training programme and in the ways in which they received supervision and support, including the monitoring of their work practices. We have made a recommendation that the service considers current advice, guidance and legislation in relation to the safe recruitment and performance management of staff, including the provider’s own policies and procedures in relation to disciplinary measures. We have also made a recommendation that the service finds out more about training for staff, based on current best practice, in relation to supporting people at the end of their life.

The service did not have an effective system in place to help monitor and improve the quality and safety of the service. The systems that were in place had not been used appropriately. There had been no senior management oversight to help ensure effective quality monitoring and improvements were carried out. We have made a recommendation that the service seeks advice and guidance about the management of and learning from complaints.

The registered provider had reported accidents and incidents to us as required. However, we found that there were other matters that had not been reported such as the closure of the kitchen for refurbishment.

We found breaches of regulation in relation to person centred care, safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, good governance and staffing. We will report on any action we take once this is completed.

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 action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.