Beechdale House Care Home

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People's care and treatment was not effective due to their health, care and communication needs not always being robustly recorded in their care plans for staff to follow to support them. Peoples care plans were not kept up to date with important information from external health teams, to ensure people received wrap around care. This left people at risk of staff not knowing how to react if people experienced a change in their condition or for ongoing monitoring of an existing health condition. This meant staff were not always aware of their preferences and therefore; these were not being respected in a person-centred way. People's individual needs were not always met by the adaption, design and decoration of the premises. The environment was not clean and tidy. Areas of the service required repairs and deep cleaning; especially people's bedrooms and communal spaces. Furniture had not been maintained, leaving people at risk of harm from unsuitable equipment to meet their needs. The provider reviewed and replaced furniture which was not fit for purpose after our assessment, but these risks had not been identified prior to our site visit. This left people at risk of harm.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People's needs were not always assessed, care and support was not always being delivered in line with current standards. People did not always achieve effective outcomes. Not all people and relatives we spoke with had been involved in regular reviews of their plans of care. People and their relatives were largely positive regarding staff being hardworking and understanding of their needs. One relative told us, “Staff worked hard and knew what they were doing.” Another relative told us how their family member’s religious requirements were respected fully, and they received a visit from their respective faith leader twice weekly.

Staff training was not up to date or relevant for the identified needs of all people who used the service. For example, specific training in fire safety, tissue viability, food and nutrition and catheter care had not been completed. This left people at risk of being supported by staff who lacked the skills and knowledge to provide safe care and support for them. We have reported on this further under Safe.

Records relating to people's care did not always contain information and guidance to enable staff to provide the safe care and support people required. For example, effective risk management was not in place for some people who were at risk due to their skin management needs, insulin managed diabetes and people who may present a risk to themselves or others from their behaviour. This left people at risk of further harm.

People's care plans lacked detail for staff to follow and were not always reflective of people's current level of need. This left people at risk of harm by not being provided with the appropriate level of support required. Care plans lacked review and had not been updated when people's needs had changed, or a significant event had occurred. For example, where people had experienced falls, we found their risk assessments had not been reviewed and updated following an incident. This meant staff did not always have up to date information about a person's needs. Where people lived with Diabetes, there was no best practice guidance for staff to follow to ensure any changes were identified in their condition. This left people at risk of harm.

We discussed the omission of specific guidance from care plans with the registered manager and clinical lead. Some people were being managed for specific conditions by external health professionals. The lack of guidance in the care plans and risk assessments for staff to follow, left people at risk receiving the incorrect support from staff and at risk of harm.

The service was not always working in line with the Mental Capacity Act. There were no risk assessments for one person's cognition. Their care plan described this person as being resistant to personal care. There were descriptions of this person being 'aggressive' which is an inappropriate term to describe a person. There was no clear risk assessment or positive behavioural support plan for staff to follow. People were at risk as no clear analysis of accident and incidents had been completed to identify any reoccurring risks or identify measures needed to keep people safe. For example, we found regular incidents of a person expressing behaviours that could put themselves and others at risk. These had not been reviewed in the persons plan of care or led to updated risk assessments for the person. The service were not effectively using Antecedent, Behaviour and Consequence (ABC) charts for people who have mental health needs. These are used to record and analyse the behaviours that people are communicating in order to provide appropriate risk management and support for them. This left people at risk of further harm due to the lack of robust review of incidents and how to provide effective management for people with complex needs.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.