Beech Haven

At our last inspection, 9 March 2023, we rated the overall service requires improvement. We identified that medicines were not always safely managed because not all medicines were safely secured, and some records were not appropriate. The provider was in breach of the legal regulations relating to safe care and treatment.

At our last inspection, 9 March 2023, we identified systems and processes for monitoring and improving quality, and for monitoring and mitigating risk were not always operated effectively. This was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We conducted this assessment to review whether the service had made improvements since the last assessment in March 2023. At this assessment we found that the provider had made some improvements to the management of medicines. For example controlled drugs were stored safely and securely , the provider had appropriate medicines risk assessments and care plans for high-risk medicines were in place to ensure that medicines risks were managed safely. Although the provider had made some improvements since the last assessment, at this assessment we found that not enough improvement had been made and the provider remained in breach of the legal regulations relating to safe care and treatment, and good governance.

The provider had quality assurance systems in place, however these were not always effective as they did not always identify where improvements were needed so these could be addressed. For example audits of medicines management and fire safety was not always being conducted effectively. Not all staff that supported people with medicines had completed the appropriate training and their competency had not been assessed. Staff told us that they complete monthly medicines audit, however the last audit was conducted in November 2024.

Audits for fire and associated risks did not pick up the concerns we noted at this assessment, examples of this are the fire risk assessment in place had not been reviewed since August 2022. It was also not signed off by the person who completed it. The detail within the risk assessment contradicted what was in place, for example we found an oil heater in a bedroom that was not PAT tested the risk assessment stated no heaters to be used.

The audits we received as part of this assessment have not assured us that the provider had oversight of the above concerns as they had not picked up on the concerns we found on the day of our assessment.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Although we had found concerns regarding the providers governance the provider had made some improvements since our last assessment. The provider had followed our advice and made changes to make the home more dementia friendly. The provider made sure there was continuity of care, including when people moved between different services, and they worked well across teams and services to support people.

People were treated with kindness, empathy and compassion and staff respected people’s privacy and dignity. The provider cared about and promoted the wellbeing of their staff and staff told us they enjoyed their roles.

There were enough staff with the right skills, qualifications and experience. Staff were positive about working at the service and told us they were supported and most of the team had worked at the service for a long time.