The Beeches Residential Home

At this inspection we found 6 breaches of the legal requirements in relation to dignity, mental health act, safe care and treatment, premises and equipment, staffing and good governance.

This service supports a large number of people living with advanced dementia, many of whom require high levels of supervision, reassurance, meaningful engagement and specialist support. Staff were generally observed to be caring, compassionate and committed to people's well-being, and relatives were positive about the kindness shown by staff. However, the service was not consistently organised or resourced in a way that enabled people to receive safe, effective and person-centred care.

Many of the concerns identified were linked to insufficient staffing levels, ineffective deployment of staff and weaknesses in leadership oversight. Although staff knew people well and were well intentioned, there were not always enough staff available to provide the level of personalised support required. As a result, care was often task-focused rather than centred around people's individual preferences, choices and wellbeing. People were not always supported to maintain their independence, choice and control, particularly during busy periods of the day.

The inspection also found that staff did not always have access to sufficiently detailed dementia-specific training. As many people living at the service experienced advanced dementia and behaviours associated with distress, staff were at times faced with complex situations they did not feel fully confident or equipped to manage. This reduced assurance that people consistently received care informed by current dementia care best practice.

Concerns identified across care planning, risk management, medicines, environmental safety, safeguarding and governance indicated that leadership oversight and quality assurance systems had not been sufficiently effective in identifying and addressing risks. There was no evidence that the provider had been aware of the full extent of these concerns prior to the inspection. Following feedback from the inspection team, the provider responded positively, demonstrated openness to learning and improvement, and sought external specialist support. The provider has also since engaged a dementia care consultant and other specialist professionals to help review practice and support the required improvements. A comprehensive action plan has been developed, with immediate action taken to address environmental risks, staffing levels, care records, medicines management and governance arrangements. While these actions were positive, many remain at an early stage and require embedding to ensure sustained improvement.

Overall, whilst staff demonstrated kindness and commitment to the people they supported, the service was not consistently delivering care that was safe, responsive and person-centred for people living with advanced dementia. Improvements were required to strengthen governance, leadership, staffing, dementia care practice and oversight.