Beechdale Manor Care Home

Updated 24 June 2022

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 was carried out by two inspectors and a Specialist Nurse Advisor. An Expert by Experience carried out telephone calls to relatives of people using the service off site, on the day of inspection to gain their opinions of the service. 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

Beechdale Manor 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. Beechdale Manor is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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. We sought feedback from the local authority, commissioners, and professionals who work with the service. 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. We contacted Healthwatch for information they held on their database regarding the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

During the inspection

We spoke with five people who used the service and nine relatives about their experience of the care provided. We spoke with 14 members of staff including the registered manager, nurses, the service administrator, floor leaders, senior care staff, care staff, maintenance staff, activity co-ordinators, housekeeping staff and the cook.

We reviewed a range of records. This included nine people's care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We contacted a health professional who works regularly with the service, to gain their opinion of the service. We reviewed records provided during the inspection relating to policies and training within the service.

Updated 24 June 2022

About the service

Beechdale Manor is a residential care home providing personal and nursing care for up to 65 people. The service accommodates people in one adapted building which is set out across three floors. The ground floor accommodates people who have a higher level of mobility and less complex needs. The first floor provides care and support for people with more complex and palliative care requirements. At the time of our inspection there were 43 people using the service. At the time of our inspection the second floor was undergoing refurbishment and was unoccupied.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

Beechdale Manor was well led by a registered manager who showed strong leadership qualities. The staff team were respectful and kind. They understood people and their identified needs well.

Risks associated with people's care and support and the environment were safely managed. People were protected from the risk of harm. Opportunities to learn from incidents was shared across the staff team to ensure improvements in service delivery were made.

Medicines were received, stored, administered and disposed of safely by staff trained and competent in this area. The home was clean and hygienic. The provider was following best practice guidance in infection control standards.

There were sufficient staff deployed across the service to meet people's needs and ensure their safety. Safe recruitment practices were followed, and staff were trained and competent to carry out their roles.

People were supported with their health needs and had access to healthcare services. Care plans contained personalised health information. The service was well adapted and being refurbished to meet people's needs.

The provider and registered manager operated effective governance systems to ensure the quality,

safety and improvement of people's care when needed. Audit systems were robust, and there were opportunities for people, relatives and staff to get involved in driving improvements.

During this inspection we carried out a separate thematic probe, which asked questions of the provider, people and their relatives, about the quality of oral health care support and access to dentists, for people living in the care home. This was to follow up on the findings and recommendations from our national report on oral healthcare in care homes that was published in 2019 called ‘Smiling Matters’. We will publish a follow up report to the 2019 'Smiling Matters' report, with up to date findings and recommendations about oral health, in due course.

Mental Capacity Act: 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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

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.

Rating at last inspection and update: The last rating for this service was Inadequate (published 18 March 2022) and there were breaches of regulation. 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.

At our last inspection we recommended that the provider made improvements to infection control within the service, safeguarding people from abuse, medications management, pressure area care management, the quality of risk assessments for service users, and improving the level of governance at the service. At this inspection we found the provider had acted on any recommendations and had made improvements in these areas.

This service has been in Special Measures since 18 March 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was 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 COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from Inadequate to Good based on the findings of this inspection.

Follow up

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