Beechdale House Care Home

Beechdale House is situated in Nottingham City. The service is registered to provide accommodation and nursing for a maximum of 40 older people and people living with dementia in one adapted building. There were 31 people living at the service on the day of our inspection visit.

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

People received safe care and treatment from staff who knew and understood their needs, including how to manage and reduce known risks. Whilst some care records needed updating, this had not impacted on the safe care and treatment provided and immediate action was taken where required, to make improvements. Staff had received training in safeguarding and health and safety. Staff were deployed effectively and safe recruitment practice was used when new staff were appointed. Medicines were managed safely and people received their proscribed medicines when they needed. Infection prevention and control measures were used, to reduce the risk of cross contamination. Incidents were reviewed and analysed to consider what lessons could be learnt to reduce further risks.

People received effective care and treatment. Recognised assessment tools, best practice guidance and current legislation, were used to assess and monitor people’s health care and well-being needs. Staff received an induction and ongoing training and support. People received a choice of meals and their hydration and nutritional needs were met. Staff worked with, and shared information across agencies to support people with their ongoing care needs. People’s health conditions were assessed and monitored, and they received support to access health services. Improvements had been made to the environment and plans were in place for further 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 were cared for by staff who knew them well. Dignity, respect and independence was encouraged. People and their relative or representative, were included as fully as possible in their care and treatment. Advocacy information was available, should people have required this support.

People received a responsive service that met their individual needs. People's diverse needs, preferences and social history was assessed and care plans provided staff with guidance. People received opportunities of social activities and community involvement. Action was being taken to appoint a new activity coordinator, to further develop people’s opportunities. Complaints and concerns were acted upon and investigated in a timely manner and resolutions found. End of life care was discussed and planned with people and their relative or representative.

The service was well-led by a management team who understood their role and responsibilities in meeting the fundamental care standards and legislative requirements. The culture of the service was open and transparent. The registered manager actively engaged and had developed a positive relationship with the community and external professionals. This had a positive impact on people. The management team were visible and involved in providing care and clearly knew people well. The registered manager used research and best practice effectively, they had been successful in achieving recognition awards for their practice and for improvements made at the service.

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 4 August 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Beechdale House Care Home 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. 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 home is run. At the time of our inspection a registered manager was in post.

People and their relatives told us that they felt staff provided safe care and support. Staff were trained in adult safeguarding procedures and knew what to do if they considered someone was at risk of harm or if they needed to report concerns.

There were systems in place to identify risks and protect people from harm. Risk assessments were in place but not all had been reviewed at the frequency required. Accidents and incidents were recorded and reported by staff. The registered manager analysed these to ensure appropriate action had been taken to protect people, and to consider if there were any themes or patterns that required further action. Contingency plans were in place to support staff to provide a safe service in the event of an untoward incident affecting the service. Staff did not always use safe moving and handling practice when supporting people with transferring.

Whilst some concerns were made about staffing levels these were found to be sufficient on the day of our inspection visit. Safe recruitment procedures were in place and followed. Medicines were given to people on time and as prescribed. Some concerns were identified with liquid medicines and topical creams that were not labelled with their date of opening. When medicines were handwritten on the medicine administration records there were not always two staff signatures to indicate they were checked for accuracy of transcription.

People were supported effectively by staff that had received an induction, ongoing training and support. Policies and procedures were in place to guide staff in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Some people had a DoLS authorisation in place or the registered manager had submitted application where appropriate. Staff had received appropriate training and understood the processes in place for ensuring decisions were made in people’s best interests. People and or their representative where appropriate, had given consent to their care and treatment.

People received sufficient to eat and drink and their nutritional needs had been assessed and planned for. People were appropriately supported with their eating and drinking needs if required, choices were offered and respected, and independence encouraged as fully as possible.

The service worked well with visiting healthcare professionals to ensure they provided effective care and support. When concerns were identified about people’s healthcare needs, appropriate action was taken to support people’s health and well-being.

Staff were kind and caring, they knew people well, and they supported people on the whole in a dignified and respectful way. Staff on the whole acknowledged and promoted people’s privacy. People felt that staff were understanding of their needs and that they had developed positive relationships with them. Information about an independent advocacy service was available for people should this support have been required.

People and or their relatives where appropriate, were involved in the assessment and review of their needs. Care plans informed staff how to support people and were on the whole personalised to people’s needs, routines and preferences. Activity staff provided a range of one to one and social activities and opportunities, to support people with any interest’s hobbies and pastimes. People and staff knew how to raise concerns and these were dealt with appropriately.

People who used the service and relatives were given opportunities to share their experience of the service. Quality assurance systems were in place to regularly review the quality and safety of the service provided. Since our last inspection the service had made some improvements and there was a plan in place to continually drive forward improvements and to sustain those already made.

Beechdale House Care Home provides accommodation and nursing care for up to 40 people. In addition to nursing needs some people were living with dementia. At the time of our inspection 26 people were using the service and one person was in hospital.

At the last comprehensive inspection on and 1 and 2 March 2016 this provider was placed into special measures by CQC. A breach of 12 legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to:

• providing care that was appropriate, safe and met people's needs,

• safeguarding people from abuse and improper treatment,

• having appropriate infection control prevention and measures in place,

• providing sufficient numbers of suitably qualified, competent and skilled staff,

• treating people with dignity and respect,

• providing person centred care,

• safe management of people's medicines,

• maintaining the premises and equipment,

• assessment and monitoring of the service,

• providing staff with appropriate support, training, supervision and appraisal,

• having a process to receive and act on complaints,

• ensuring all conditions of registration with the CQC were being met.

During this inspection we found that some improvements had been made and these breaches in regulation had been met. However, we identified further work and time was required for improvements to fully embed and be sustained.

Beechdale House Care Home 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. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008. At the time of our inspection the registered manager was no longer working at the service. A new manager was in post and they were in the process of submitting their registered manager application. We will monitor this.

Improvements had been made to how people who used the service were protected from abuse and avoidable harm. Where concerns had been identified the provider had taken correct action in informing the local authority responsible for investigating safeguarding’s and had informed CQC. Staff had received adult safeguarding awareness information and further training had been planned for.

Risks associated to people's individual needs had been assessed and planned for. We found the information provided to staff of how to manage known risks were variable. Accidents and incidents were recorded and action had been taken to reduce risks from reoccurring. However, the provider lacked systems and processes that analysed events that would provide oversight of any patterns, trends and themes.

Improvements had been made to the premises and equipment. The premises were found to be safe and equipment had been serviced and new clinical equipment purchased.

The cleanliness of the service had improved. Additional domestic staff had been employed and cleaning schedules reviewed and improved. The service had recently had an infection control audit completed by the local clinical commissioning group. The provider had developed an action plan in response to the shortfalls identified.

The provider had completed appropriate recruitment checks before staff began work to check their

suitability. A dependency tool had been introduced that determined what staffing levels were required. Staffing levels had increased to ensure people’s needs and safety were appropriately met.

The management of medicines had improved, but no protocols were in place for people that had prescribed medicines to be taken as required.

The support available to staff had improved. Staff received an induction to support them to understand their role and responsibilities. Staff had received opportunities to discuss their work, training and development needs. Staff meetings had been regular and was an additional method used to support staff.

The manager understood their role and responsibility in ensuring the Mental Capacity Act 2005

and Deprivation of Liberty Safeguards legislation was adhered to. Where required people’s capacity to consent to their care and treatment had been assessed and best interest decisions had been made appropriately. However, staff’s knowledgeable about the principles of this legislation was very limited. Where people were deprived of their liberty this was done in accordance to the authorisation in place.

People received sufficient to eat and drink and the menu choice was based on people's needs and

known preferences. Staff were aware of people’s dietary and nutritional needs and external healthcare professionals were involved when concerns were identified.

Staff supported people to maintain their health, this included accessing both routine and specialist

healthcare services. The service involved external health and social care professionals

appropriately in meeting people's individual needs. Improvements were found how people’s daily care records and charts were being completed. However, their continued to be a lack of monitoring or oversight of these records. Where it was identified that a person’s repositioning chart had not been fully completed staff were disciplined.

Some people required support to eat and drink but this was not always provided by staff in a caring, dignified or respectful manner. There was inconsistency in the care, kindness and compassion shown by staff. Care provided was often task led as opposed to being person centred.

The opportunities for people to participate in activities had improved. Plans were in place to develop and introduce further opportunities. It was unclear if these activities were based on people’s interest, hobbies and pastimes.

A complaints policy was in place and staff were aware of how to respond to any complaints or

concerns made. People who used the service, relatives and visitors had access to this information. Where concerns had been raised with the provider these had been responded to appropriately and in a timely manner.

Opportunities for people who used the service, relatives and representatives to be involved in meetings about their care and treatment were being developed. People had been assigned new named nurses and keyworkers and this information had been made available for people.

People that used the service, relatives and staff were positive that improvements had begun to be made to the service. The provider had made improvements in the way they were monitoring the quality and safety of the service. They had also identified further improvements that were in the process of being implemented. A new manager was in post that was responsive to the continued improvements required to further raise quality and standards.

Beechdale House Care Home provides accommodation and nursing care for up to 40 people. At the time of our inspection, 30 people were using the service. The home is set on a main road and has two storeys. Two of the rooms were shared, and the rest were single rooms. There were communal bathrooms and toilets. There is one lounge and a separate dining room.

At our last inspection of the service on 10 February 2015 we identified that there was a breach of Regulation 13 of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2010. The registered person did not have suitable arrangements to protect service users against the risks associated with unsafe management of medicines. At this inspection we found that further work was required in this area.

There was a registered manager in post at the time of our inspection. 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.

People were not always protected from the risks of harm or abuse. Staff we spoke with knew what to do if abuse was suspected, but we were not confident that the service always made referrals to the local authority in a timely way.

Risks had not always been managed to keep people safe. Risk assessments had been completed but these were not always acted upon, which meant people could be left at risk of harm.

We were not confident that people who required medication received this as the prescriber had intended. Not all staff who administered medicines had completed an annual assessment to assess their competency in the area. Medication audits were not being regularly done to check any areas that required improvement. This meant that there was a greater risk that errors would be made.

Action had not been taken in a timely manner to ensure the environment was maintained in a safe way. Substances and equipment were accessible that could have posed a serious risk to people’s safety. There was no schedule of servicing for some medical equipment, and we had concerns about fire safety, the lack of an up to date gas check certificate and electrical certificates. This meant we were not sure people were safe in the environment of the service.

Two recruitment records we looked at did not contain the mandatory Disclosure and Barring checks (DBS).The provider told us they were agency workers but not all of the files we checked were agency workers. One staff file had handwritten references on scraps of paper from an unidentifiable person. This meant we could not be sure that all staff had been safely recruited.

The provider was not using any tool to help them decide on safe staffing levels. There were insufficient staff to meet people’s needs and manage risks.

The environment was not clean and this increased the risk of infection spreading. There were insufficient cleaning staff on duty. Chairs and furniture were not always clean. There was a lack of hand washing signs and hand gel dispensers.

The training given to staff was not always sufficient to ensure people had the skills and knowledge they required to do their job. This was because staff training information was not available for all staff, and not all staff had undertaken training that was required. Some staff were not receiving regular supervisions.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was not acting in accordance with the MCA, including DoLS. The provider had referred all people using the service for a DoLS, when not all of the people lacked capacity. There was a person already subject to a DoLS but the provider was not meeting the conditions of the DoLS, nor did staff realise the person was subject to a DoLS. This meant the provider was failing to follow accurately the MCA and DoLS processes, and people may not have had their rights fully protected by the law.

Adequate food and drinks were provided, but we did not see evidence that people were always offered choice, or appropriate support with their dietary intake.

People’s privacy, respect and dignity were not always maintained. We saw people were sometimes not kept private when accessing the toilet, people were spoken to inappropriately, and someone was left in a wheelchair facing the wall for over an hour. People in distress, or need of support were not always responded to in a dignified or caring manner. Some staff showed care towards people, but we noticed this appeared to be directed at more able people.

People were referred for their health needs to GPs and other relevant health professionals.

Staff did not always approach people in a caring way. Whilst we saw three staff show care towards people, other staff spoke across people and ignored their signs of distress.

People’s privacy and dignity was not always respected or promoted. People were not always supported to express their views or be involved in decisions about their care. People were not always offered a range of activities suitable to their needs and preferences.

People were not always responded to in a timely way when they needed support. We saw a person who needed to use the toilet and no staff were available to help. We had to call the registered manager to give support.

Although there was an activities timetable, there was no dedicated activity coordinator and people were not always offered activities suitable to their needs and preferences.

We could not be sure that care plans contained all the relevant information to ensure people’s needs and preferences could be met. The complaints procedure was not adequate.

There were insufficient quality audits and checks to demonstrate that the provider was making improvements and listened to people’s views to improve the service. There was limited opportunities for people and their relatives to give their views of the service as the annual questionnaires showed that many replies had been completed by staff.

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.

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.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

All three people told us they were very happy and settled living at Beechdale House and staff looked after them well. One person said, 'The staff are pleasant, they are on hand if you need anything. I enjoy walking around, going out and socialising with others.' Another person said, 'I am happy and settled living here, I enjoy it and the staff are nice.'

However we found care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

We also found there were ineffective systems in place to reduce the risk and spread of infection. Nevertheless people spoken with told us they felt that the home was clean and tidy. One person said, 'It's kept clean.' Another person said, 'My room is nice, it is kept clean and tidy.'

One relative said, 'There is no smell, it's kept very nice.'

Although the provider continued to improve the environment we found they had not fully taken steps to provide care in an environment that was suitably designed and adequately maintained.

We spoke with two people about the environment and asked them if they felt it was maintained. Both of them told us they felt the environment was well maintained. One person said, 'It's mostly well maintained.' Another person said, 'I have a nice room, it is kept nice and it has just been redecorated.'

We saw that effective recruitment and selection processes were not always in place.

Although there were some gaps in staff training we saw they were being offered training to develop their knowledge and skills in relation to the job role they were to perform.

The provider was monitoring the quality of care being delivered but they were unable to fully demonstrate that there was an effective system in place to monitor the quality of the care and support being provided to people and make the necessary improvements.

We saw some records were not always accurate and fit for purpose and had not always been stored securely.

Last time we visited we had some concerns about the way some members of staff referred to people and about staff not noticing when a person's dignity was compromised. This was not best practice and we asked for improvements to be made. During this visit we saw the provider had met with staff and reminded them of the importance of supporting people to maintain their dignity. We observed staff interactions with people and we saw staff were patient and respectful and people were addressed appropriately.

We spoke with two people using the service about their privacy and dignity being respected by staff. Both people told us they did not have any concerns in relation to this and one said, 'Staff talk to me very nicely. They have never been disrespectful.'