The Beaufort Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider’s systems and processes to oversee and improve the quality and safety of the service failed to keep people safe. Leadership was new to the home, from manager to regional manager. The registered manager had left the service, and a new manager appointed. There was no information handed over to the new manager to ensure a smooth transition and understanding of key priorities. Processes to complete daily walk arounds of the environment were not completed, fire safety and water quality checks went unchecked. These incomplete checks had not been identified by the provider. There was no evidence of organisational learning at provider level. This meant some of the issues we found again had been raised to the provider at previous inspections. Staff felt supported by the new manager and were able to raise any questions or concerns they had.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager, regional manager and estates manager had been in post 5,9,and 6 weeks respectively. It was clear there was no communication or handover from the provider to incoming managers. There was a lack of ownership to the current issues and limited ideas in how to identify and resolve the issues. During our on-site assessment, another health care provider took ownership of improvements, but we had no information from Roseberry Care Limited, the CQC registered provider for The Beaufort Care Home, why this was until after our assessment was completed.

We found no evidence from this assessment, the organisation had not learnt from previous inspections and learnt from their own quality assurance processes. We found repeated breaches of regulations and additional regulations that through a lack of oversight and learning, put people at unnecessary risk. The provider has and continues to not understand how learning from inspections and action plans help drive standards. We have identified the same issues around risk management, medicines management and a lack of effective governance. This shows a lack of effective strategy and vision to improve.

Conversations with managers showed a lack of consistency leadership. A regional manager said none of the issues we identified at our site visit had been communicated to them. The registered manager had left the service and a new manager had been in post for 5 weeks. The leaders told us that the lack of effective and robust processes meant already identified issues had continued. The issues we have identified in this report showed the providers leadership was not always capable to provide safe and good care.

Process to monitor training statistics showed gaps in staff being training in all areas. Some staff training completion was as low as 50% completion in some key areas. Where issues were identified by us during our visit such as risk management, medicines and fire safety, training completion was less than 80% completed. Processes to oversee the service and its governance had not been completed or monitored to ensure where actions had been found, actions had been taken.

Nursing staff told us they did not have any competency checks or observations on their practice to help give them confidence in their practice. Nurse staff said they had collectively approached management to address their concerns. At the time of our visit, they told us no assessments of their practice had yet taken place. Staff felt confident to report, whistle blow and raise concerns if needed. Staff were positive about the recent management changes who were open and listened. Staff meetings were planned in the future. If staff had concerns and the provider had not taken action, staff were confident to raise their concerns to us (CQC). Staff were not aware of any ‘speak up’ officers within the provider group but they knew what to do.

Staff had not yet had meetings with the new manager, but these were planned to take place. The manager said they had an open door and staff said they could approach the manager if required. Nursing staff told us they had raised their concerns about supervisions and competency, and we were told by the regional director, those assessments would be arranged. The regional director said they wanted staff to raise any feedback with them to help them make the necessary improvements.

Staff told us they felt valued. Staff said they felt their individual needs and preferences were respected, for example, a staff member returned from sickness and wanted to change roles to activity co-ordinator. This was supported. Staff from countries outside of the UK felt part of the team and they enjoyed working at the home. Staff team said they worked well together, with good communication.

To support recruitment, staff were recruited from overseas. Recruitment practice supported that and processes include appropriate checks. Staff felt supported by the employer, for example with shift patterns. One staff member told us they wanted to help people with activities and hobbies and that was supported.

The manager and regional manager told us they had been here a short time and were not aware of the issues we told them about, especially related to medicines management, fire safety and overall governance. The manager said some checks were the responsibility of nursing staff, others by maintenance staff. We found limited evidence of any checks were made. The manager told us they completed daily walk arounds to make sure the premises and practices were safe; however we found a significant amount of gaps in their completion. Nurses and senior staff told us they were responsible for management of the shift and medicines; however it was clear there were gaps in their knowledge, training and competence. They also told us it was difficult to oversee the shift, complete medicine rounds and meet with other health professionals.

The manager and regional manager had no knowledge of the scale and severity of the issues that needed improvement in the home at the time of our assessment. The manager told us audits and checks were completed, in some cases actions had been identified. However, none had been taken. For example, a provider audit completed June 2024 identified similar concerns to us, yet no actions or follow up actions had been made to improve the service. Where checks were delegated to others, there was no evidence to show those checks had been undertaken. Environmental concerns such as water quality and fire safety were not always completed. Daily checks were not always completed so issues remained undetected with some unsafe medicine’s practices putting people at risk. Medicines audits did not check some medicines so the provider could not be confident, processes kept people safe. We found similar issues at the last inspection. This was a continuing breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and relatives said they had access to chiropody, district nurses, GP and an optician when needed. We saw care staff supported people pre/post hospital appointments and relatives and people were complimentary of the support. During our visit, we saw paramedics assisting to someone with nurse support providing important information. Families said communication and how that information was provided was good.

Staff told us they could make any referrals to health professionals via senior staff. Staff told us if health professionals were involved, they were kept informed. Staff and nursing staff said they worked well with other health professionals. We saw a nurse support paramedic staff. However, staff’s knowledge of providing important time critical meds went unrecorded. Pain patch meds were not applied as directed, blood sugar levels were not always clear why levels where high or low. Conversations with nurses showed a lack of responsibility and a lack of seeking further advice. We found specialist advice to support people to minimise the risk of choking was not followed and not completely understood.

A health professional told us they had good links with staff at the home. They told us staff shared information with them and if any information was passed to staff, that was followed. We found in some cases from other health professionals involved in people's care, some advice was not always followed or if changes occurred, further advice may not have been sought.

Care records demonstrated staff worked with healthcare professionals to ensure people received safe care, e.g, Speech and language therapists and GP’s. However, we found staff did not always follow that advice. Blood sugars were checked but it was unclear when and actions to take if blood sugar levels were high. The cook provided a person a pureed meal instead of soft and bite size, without seeking further advice. Processes of checks included daily safety huddles, but these were not completed at the required intervals.

Very limited feedback from staff about learning and improving. Most staff and leaders we spoke with were new to the service. The nurse had been at the service for 3 months, the manager 5 weeks, a regional manager 9 weeks and an estates manager 6 weeks at the time of our visit. Staff did say they had asked for competency and observed practices to help give them knowledge and confidence they were doing things right. This had not yet happened. A regional director said they did complete lessons learnt across the provider group, however, that learning had not been evidenced at The Beaufort. Issues identified at the last inspection at this home had not been improved so we could not be confident, lessons were learnt to drive standards.

There was limited evidence of learning from audits, guidance or regulation. This provider at this location had a history of not learning through CQC Inspections. Previous to this assessment, previous ratings have always been requires improvement or Inadequate. We have identified again, repeated breaches of the same regulations as found at previous inspections. The providers processes to ensure a robust and effective governance processes was not able to demonstrate improvement by learning from previous inspections.