The Beaufort Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not safe. We found breaches of regulation in relation to safe care and treatment, medicines management, premises and equipment, good governance and safe and effective staffing. We assessed all quality statements in the safe key question and found significant areas of concern. People received care from staff that had not received the required training or competency checks to support them with the administration of safe medicine management. Staff administering medicines failed to administer some medicines in line with manufacturer or prescribers’ guidance. Staff levels did not always make sure, people’s care needs were met at times they preferred, by staff who were suitably trained. Risks to people were not managed well especially for people at risk of choking or who had health conditions that required regular monitoring and medicines at specific times. Risk assessments were not completed effectively when people were supported to manage their overall health and welfare. This placed people at risk. Premises and equipment were not safely maintained and some staff were not trained or understood how to complete fire safety checks. We found significant gaps in the checking and effectiveness of certain fire prevention measures by the management and provider. Lessons learnt from limited audits and previous inspections had not been evidenced through improved practice.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives told us they were pleased with the service they received. Where people raised concerns, such as with the standard of their room, people’s wishes were respected, and changes were made. The registered manager had left and a new manager had been at the home 5 weeks. Not everyone knew who they were, however, people said they would raise concerns.

We found the manager, regional manager and estates manager were at first, not aware of the issues we found at this assessment at The Beaufort. We discussed with them what we found, namely similar issues as at the previous inspection. There was no handover for those leaders above to address any known concerns and it was clear there was no learning taken from previous inspections. A director told us learning was taken from incidents and known examples, however they accepted this was not always in place at The Beaufort.

We reviewed the quality assurance systems and processes that would help identify any improvements or planned actions through the provider’s own learning. We did not see any evidence that lessons had been learnt. Some completed audits failed to improve practices or make sure those actions were addressed. Since the last inspection, similar and new concerns had emerged putting people at unnecessary risk of harm. This included a lack of effective clinical and environmental risks. We could not be confident staff had the knowledge and confidence in their role.

People and their relatives told us they felt their service worked well with other health professionals such as the doctor, optician and district nurses. People told us they received continuity in the staff who provided their care. One family member said, "[Relative] has been here since last March, they came for an assessment, and we asked for them to stay.”

Staff gave us examples when they could request GP support when needed, or if people needed support from a speech and language therapists. Staff said they had a daily handover which gave them information about other health agencies involved with people’s care. The manager said people had hospital passports and important information went with that person if they went into hospital to ensure continuity of care was provided.

Feedback from partners was positive that showed care and support was planned and organised with people, together with staff to ensure continuity. A health professional told us they held multi-disciplinary meetings with community nursing, the home manager and the person and their families if concerns were raised.

Daily records and care plans showed where other health professional input had been sought. During our visit, a health assessor worked with a family to ensure the care their relative received continued to be right for them. The manager told us they had a planned admission and pre assessments had been completed to ensure the person’s needs could be met. However, we were not confident in some cases, that guidance was followed, for example, one person identified as requiring a modified diet received meals prepared in a way that did not match specialist advice.

Majority of people felt safe living at the home. Relatives felt their family members were safe. Comments included, “We are relieved that there’s always someone on the spot to help them”, and "They know [Relative] so well here, we know that.” A couple of people told us staff were not so gentle as others and they had raised those concerns.

Staff told us they were trained in how to recognise and report abuse. Staff knew how to escalate concerns, and they were confident any concerns passed to the manager would be actioned. One staff member said, “I would remove the staff member and report it to the manager.” Staff told us they felt confident to reports poor practice and if nothing was done, they would contact CQC.

We saw staff speaking appropriately to people in communal areas and in people’s rooms. Staff engaged people when supporting them or when helping them mobilise around the home. We saw scratches on one person’s arms (NB) who told us staff scratched them when helping them to move in bed. Staff had documented where scratches or bruising had occurred. Staff did not rush people and behind closed doors, we heard staff being respectful to people.

Safe systems included a review of reported safeguarding incidents, the manager was planning to do observed practice and supervisions of staff to check they supported people safely. The manager said planned meetings would be an opportunity to discuss any safeguarding and how to keep people safe.

People told us they felt safe, especially if staff transferred them or helped them with daily tasks. One person told us they felt staff knew how to limit risk, they said, “Generally they move me safely and they don’t hurt me. I have a stand to get me up and it works quite well.” A relative said their family member was at risk of falls and said, “[Relative] is safe, we are relieved that there’s always someone on the spot to help them.”

Care staff explained how they managed risks, by reading people’s care plans. However, we found staff who administered medicines were not aware of the risks people faced, for example when they needed time critical medicines. Staff who prepared a meal for a person on a modified diet, changed the consistency of the meal without seeking further advice from a speech and language therapist. Staff did not know when and how to make some fire safety checks to keep people protected in the event of a fire. A lack of effective risk management strategies put people at unnecessary risk of harm.

We could not be confident, people received their medicines safely, especially people requiring time sensitive medicines. Our observations showed the morning medicines round took around 4 hours to complete. We reviewed care plans that had been updated during our visit. We found those reviewed care records were still not correct. We found 6 fire doors were not correctly adjusted which may not prevent the spread of fire or smoke. We also found a significant number of window restrictors were not to standards. Our observations also confirmed what people told us, the temperature in the home was too hot for them. The estates manager told the boiler had a faulty valve and was not able to be adjusted during our onsite visit.

Processes to manage risks to people were not effective. Risks related to medicines were not always safely managed. We found medicines to manage diabetes had no individual names on them and no dates of opening. Medicines in patch form were not applied correctly to people’s skin site in line with manufacturer’s instructions. There was no process to ensure people who needed medicines at specific times received them when they needed. Some risks related to water temperature and fire safety checks were not always completed at required internals. The provider had not identified people’s care records and risk scores were not consistent with each other. We found people’s risk management records were not reviewed or in some cases, did not contain the relevant information to help staff provide consistent care. This put people at increased risk of harm. The provider failed to robustly assess all necessary risks relating to the health safety and welfare of people. This was a continuing breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People raised no concerns about cleanliness or the home in general. People liked their room and some people told us their room was clean. Some people told us the home was too hot. People said to us they wanted to go into the garden but this was not always supported.

Staff told us they had no concerns about the environment, other than the temperature in the home which was excessive. Staff told us the home had been like this for some time without anyone looking at it to make the temperature more comfortable. Staff said the garden area had recently been improved. Daily walk rounds completed by the manager identified areas of concern and this was then discussed with staff so action can be taken to resolve the problem. However, we found some daily walkarounds had not been completed which meant some issues we found went unnoticed, or, they had failed to record what actions were taken.

We found a significant number of concerns with the environment that put people at unnecessary risk of harm. For example, in the communal hallway there was a large full jar of sugar. This presented a risk to people who were diabetic. We saw a number of window restrictors without tamper proof fixings and in one example, the window lock was not attached, meaning the person could fall from height. The communal shower room had full soiled linen next to wheelchairs and commode chairs. We found 6 fire doors were not correctly adjusted which may not in an emergency stop the spread of fire.

Processes to ensure the premises were safe, failed to identify risk. Fire safety door checks were not completed, and some doors were not checked frequently to ensure they remained fit for use. Fire emergency lighting had not been checked as safe since March 2024. Staff trained in fire drill training was 77.1% and fire safety practical training was 71.4%. Records showed not all staff were trained in fire safety. We were told the boiler in the home was stuck on ‘winter setting’ and made the internal temperature of the home too hot for some people. No staff knew how to adjust the temperature to a more comfortable level. The manager did not know these issues were present in the home and the maintenance person was not trained or assessed as competent to make those changes. Processes to keep a safe environment were not effective to keep people safe and protected from risks. This was a breach of regulation 15 (Premises) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were complimentary of staff but said there were not enough staff to meet their needs. One person said, “I have a call bell sometimes when I use it they don’t come at all other times they are quite quick. It’s worse at night once I wanted the light off and they didn’t answer and the light was on all night.” Another person told us they had their bed clothes changed at 5.30am which they did not like or had asked for. Other comments were, “If I want the commode you have to wait and wait”, “I’d like to go outside if only for half an hour, I’ve asked many times but they say they’ve got no staff” and “When I first came they used to give me showers now I get a sort of a wash, I don’t think there’s enough staff, I have to wait for everything.” One relative said their family member was always in their room, but they were downstairs for the first time during our visit. They said to us, “That’s because you are here."

Four out of 5 staff told us current staff levels had decreased. Staff said they only provided task-based care. Staff told us the mornings were busy and an extra staff member would make it easier to provide care to people when they needed it. Staff said at times there was limited time to spend with people. A staff member said losing a senior carer role impacted on the time it took to complete the medicines rounds, especially when nurses were stopped to support GP’s and other clinical emergencies. When we told the manager people said they did not go outside, staff brought people into the garden area which people enjoyed. People spent time in communal areas and some people spent time in their own room. There was limited mental or physical stimulation for people.

On occasions we saw people did not have drinks, or people told us when they had drinks, they had gone cold and went undrunk. We saw staff supported people when people required help. During our second day, a number of contractors were making repairs within the home. We saw contractors had their meal before those people living in the home, whose meal was served to them, 40 minutes than usual. We saw the medicines round took a long time to complete which could cause problems for people who received time critical medicines or medicines a certain time before food and drinks.

The manager used a dependency tool to calculate staffing levels on shift. The manager said staff levels were based on people's risk; however we saw some people’s risks were not correctly assessed correctly. Staff and the regional manager said staff levels had been reduced by 1 in the last 6 weeks without any proper review to determine the impact. Not all staff were assessed as competent, for example when administering medicines. During our visit, a new person was moving into the home. The manager confirmed staffing levels had not been reviewed to see if there was any impact on current staffing levels. We saw 1 care staff member doing housekeeping duties and the manager had not been made aware, which reduced the number of care staff supporting people in the home. People, staff and our evidence show there was no effective processes to ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service. This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People had no concerns with overall cleanliness. One person said, “They always clean my room.” Relatives said they attended the home and found no issues with cleanliness. One relative told us of an occasion where cleanliness and odours in a part of the home were causing their relative some problems and this was resolved to their satisfaction.

Staff had sufficient stocks of personal protective equipment (PPE) and demonstrated an understanding of what they would do in the event of an outbreak. A staff member told us how they disposed of the used PPE safely in clinical bins. Housekeeping staff kept the home clean and ensured clinical and waste bins were emptied.

Overall, the home was clean and there was ongoing refurbishment in some areas of the home such as painting. However, we saw in a communal bathroom, equipment such as commode chairs and wheelchairs were kept in a walk-in shower cubicle, next to a soiled bag of laundry items. This presented a risk of cross infection. There were posters displayed to remind people of hand washing and there were full soap and paper dispensers in place to support safe hand washing practice. We saw clinical and waste bins had been emptied.

Processes were not effective to make sure any issues or omissions had been identified. Processes included a daily walk around and a daily safety huddle, but we found these were not completed daily. Other processes included checks of equipment, but we found some checks on where and how those were stored did not support safe infection prevention and control measures. Some audits identified infection and prevention issues, but there was no evidence or records or actions taken.

People said they got their medicines when they needed. People said staff waited for them to take their medicines. Relatives’ were confident medicines were given to their family member when needed, for example to help with occasional pain relief. Not everyone knew why they had some medicines, but no one raised any concerns to us.

Nurse and senior staff were not confident or aware of how some medicines needed to be given to some people to ensure their health and welfare was maintained. We found some patch medicines were not applied correctly which could cause skin irritations or for the medicine not to be effective. None of the staff who administered medicines could tell us what times people had their time sensitive or time critical medicines or if they had the right time gaps between each medicine. Staff told us they were not aware they had to record times those medicines were given. When we discussed specific people, it was clear from staff’s knowledge they did not know how to give specific medicines. The manager had limited or no oversight. The manager said they were not aware of the issues we found, then arranged for some changes to care records and medicine administration records (MAR). When we checked those corrections, they were still not accurate.

There were no effective processes to make sure people received their medicines safely. One process included a monthly audit of medicines, but we found it did not check medicines disguised in food or drink, for medicines requiring stricter controls and for insulin. The last medicines audit dated July 2024 scored 96.2% yet the issues we found had been scored good, or had not been identified. We found medicine counts were inaccurate and in one case, a person had run out of their prescribed thickener to be given in their fluids on the morning of our visit. People’s records and MARs did not always have a current photograph, room numbers were not where people resided, with no room numbers on people’s MARs which increased the risk of people receiving medicines that may not be for them. There was no audit of topical creams and ‘as and when’ medicines and limited checks on MAR accuracy and completion. We noted untrained staff acted as a second signatory for more stringent medicines which was not in line with good practice principals. This was a continuing breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.