Beechwood Care Home

At the last inspection, we found breaches of regulations relating to the quality and safety of the care and treatment provided, and the governance of the service. We also identified a breach around failing to submit notifications to the Care Quality Commission (CQC).

At this inspection, whilst some improvements had been made, the service remained in breach of regulations relating to safety and governance.

There were significant and ongoing concerns about the consistency and safety of care, and the service was not always safe or well-led.

Governance systems had not been effective in identifying and addressing risks. Environmental risks were not consistently managed, including concerns relating to fire safety, infection prevention and control, and the overall condition and cleanliness of the premises. For example, fire doors did not always close properly, communal areas were cluttered, and some equipment and fittings were damaged or difficult to clean. Infection prevention and control practices were poor, with inappropriate storage of personal protective equipment, ineffective checks on cleaning standards, and poor laundry arrangements where clean and soiled items were stored together. These issues increased the risk of avoidable harm to people.

Care records and medicines management required improvement. Protocols to support people who were prescribed medicines on an ‘as and when’ basis were incomplete. Topical cream records lacked clarity, and transdermal patch rotation records were not maintained in line with guidance. Daily care records were often inconsistent, with gaps in the recording of food, fluid intake and repositioning monitoring.

People were not always supported in a timely way, particularly on the nursing unit, where staff did not always recognise when people required assistance with eating and drinking or encouragement to engage.

Staffing arrangements did not always ensure people received consistent care. We identified examples of ineffective handovers and staff lacking knowledge of people's individual needs. While people generally told us they felt safe, some relatives raised concerns about people going into other people’s bedrooms at night and expressed a wish for greater consistency in staffing.

Despite these shortfalls, there had been some improvements since the last inspection. An interim manager who had been in post for four weeks at the time of the inspection had introduced a number of changes, including daily flash meetings, weekly weight and wound reviews, increased managerial oversight, and greater involvement of relatives in menu planning and activity choices. People, relatives and staff described some positive impact from these changes.

People and relatives gave largely positive feedback about the caring approach of staff. People told us they felt safe and supported. They and their relatives consistently described staff as kind and caring. One person told us, “I love it here, I really do. I buzz and they're here straight away.” Relatives told us, “We know the staff genuinely care; they always update us.” Staff were observed to treat people with kindness and respect, and some compassionate, positive relationships had developed between people and staff. There were signs of improvement, but they were recent and insufficient at present to mitigate the significant and longstanding failures in leadership, governance and oversight.