This inspection site visit took place on 16 July 2018 and was unannounced. Beech Court Nursing Home is a ‘care home’ with nursing. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to accommodate up to 26 older people, some living with dementia, who require personal or nursing care. At the time of the inspection there were seven people living there.

The provider is registered with the CQC as an individual and therefore it is not a condition of their registration that they have a registered manager. The registered provider has legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last comprehensive inspection in November 2017 we asked the provider to take action to make improvements to infection control. This action has been completed. We found peoples’ rooms and communal areas were clean and there were no lasting odours around the building. Staff followed good hygiene practice.

At the last comprehensive inspection in November 2017 we asked the provider to take action as quality audits were not being used effectively to ensure improvements were made where necessary, such as around infection control. This action had been completed. Audit systems were in place and being effectively implemented. We noted improvements in the quality assurance systems to both monitor and improve the governance of the service.

The provider acknowledged that the service having a registered manager who would have day to day oversight of the home would ensure that these improvements could be sustained as and when occupancy increased. The provider showed a commitment to recruit a registered manager to improve leadership and guidance for staff.

People using the service told us they felt safe living at Beech Court and relatives we spoke with agreed. People were kept safe from avoidable harm because the staff team had received training on safeguarding and understood their responsibilities.

The risks associated with people's care and support had been assessed, monitored and reviewed. People received their medicines as prescribed.

Appropriate pre-employment checks had been carried out on new members of staff to make sure they were safe and suitable to work there. There were sufficient staff to meet people’s needs and spend time with them.

New staff were provided with appropriate induction into the service and on-going training was being delivered. This enabled the staff team to gain the skills and knowledge they needed in order to meet people's needs. Staff were also supported through regular meetings with their manager and an annual appraisal.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People who used the service and relatives consistently told us staff were kind, caring, patient and upheld people's dignity. Care plans were personalised and centred on people's preferences, views and experiences as well as their care and support needs.

People and relatives knew how to raise any concerns and were confident these would be dealt with effectively.

People who were receiving end of life care were provided with compassionate and skilled care with appropriate involvement from health professionals as needed.

We have made a recommendation about consulting with current best practice guidance about developing a dementia friendly environment.

This inspection took place on 21 November 2017 and was unannounced.

Beech Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Beech Court nursing home is registered to provide accommodation for up to 26 older people, some living with dementia, who require personal or nursing care. There were six people living at the service at the time of our inspection.

The provider is registered with CQC as an individual and therefore it is not a condition of their registration that they have a registered manager in post. The registered provider has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in April 2017 we found the provider was in breach of three legal requirements. We asked the provider to take action and make sure people received safe care and treatment and to make sure and to make sure people were supported in line with the principles of the Mental Capacity Act (2005). We also rated the well led section inadequate due to continuous ineffective quality assurance systems. Following our inspection in April 2017 we imposed conditions on the provider’s registration to restrict any new people being admitted to the service and to require monthly reports of actions they were taking to improve. At this inspection, we found some significant improvements had been made. However, more improvements were still required in some areas.

People told us they were safe. The provider had made improvements in relation to people’s safety. Risks to people’s well-being were assessed and managed safely. Staff were aware of people’s needs and followed guidance to keep them safe. Staff clearly understood how to safeguard people and protect their health and well-being. There were systems in place to manage safe administration and storage of medicines. People received their medicine as prescribed. However, we found the provider still needed to improve their infection control practices.

The manager and staff understood the Mental Capacity Act 2005 (MCA) and applied its principles in their work. The MCA protects the rights of people who may not be able to make particular decisions themselves. Where people were thought to lack capacity to make certain decisions, assessments had been completed in line with the principles of MCA. The manager and staff understood their responsibilities under the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be deprived of their liberty for their own safety.

The provider had been more involved with the running of the service since our last inspection and had introduced a number of quality assurance systems, with the support of an external consultant, to continuously assess and review the quality of care people received. Some of the quality audits worked effectively to identify areas of improvement and we saw significant improvements in those areas. However, some audits were not always completed correctly. We also found some people’s records were not updated where changes in their needs had occurred.

At previous inspections we have found concerns in relation to a lack of activities for people living at Beech Court. At this inspection we found the provider had tried to make changes and introduce new ways for staff to engage with people. However, some people and relatives still told us that activities did not always meet people’s preferences and individual needs.

We have made a recommendation about person centred activities.

Beech Court had enough suitably qualified staff to keep people safe. We saw people were attended to without unnecessary delay. The home had robust recruitment procedures and conducted background checks to ensure staff were suitable for their

We inspected this service on 4 April 2017. This was an unannounced inspection. Beech Court nursing home is registered to provide accommodation for up to 26 older people some living with dementia who require personal or nursing care. At the time of the inspection there were eight people living at the service.

The provider is registered with CQC as an individual and therefore it is not a condition of their registration that they have a registered manager in post. The registered provider has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 28 June and 1 July 2016, we found four breaches of the regulations. We asked the provider to take action to make sure people received safe care and treatment and to make sure people were supported in line with the principles of the Mental Capacity Act (2005). We also issued a warning notice telling the provider to improve their quality assurance systems. At this inspection on 04 April 2017 we found some improvements had been made, but improvements were still required in three areas.

People’s mobility equipment was now stored in a way which kept it accessible in case of emergencies. People’s records were kept confidentially and staff understood and respected confidentiality.

People had improved access to activities and stimulation from staff in the home. However, improvements in variety could still be made.

Since the inspection in June 2016 the provider had appointed a manager, who was not registered with the CQC. The manager had introduced some quality assurance systems, but these were not always effective at regularly identifying and driving improvements in the service. The provider did not operate any of their own quality assurance systems to ensure they were confident that they were delivering a high quality service. The provider demonstrated a lack of understanding of the regulations and how to implement good governance to ensure the regulations were met.

People were still not always protected from the risk of pressure sores as pressure relieving equipment was set incorrectly. Risk assessments and management plans were not always completed.

We also identified further concerns. People’s medicines were not always stored safely. People’s care records contained conflicting, inaccurate information and were not always person-centred.

Staff understood the principles of the Mental Capacity Act 2005. Where people were thought to lack capacity, some assessments in relation to their capacity had been completed However, these assessments were not always recorded in line with the principles of the MCA. Staff understood their responsibilities under the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

Beech Court has an extensive history of not meeting the regulations since registration in 2010. The provider has not made sustained improvements to the service to ensure people’s safety and implement good quality assurance systems.

The provider followed safe recruitment practices. There were suitably qualified and experienced staff to meet people's needs. However, staff told us there were not enough staff to keep people safe. There was a significant amount of time when people sat during the morning with no staff interaction.

People who were supported by the service felt safe. Staff had a clear understanding of how to safeguard people and protect their health and well-being. People’s medicines were administered safely.

People’s nutritional needs were met. People were given choices and received their meals in timely manner. People were supported with meals in line with their care plans.

Staff knew the people they cared for and what was important to them. People's choices and wishes were respected and recorded in their care records.

Where people had received end of life care, staff had t

We inspected Beech Court Nursing Home on 28 June and 1July 2016. This was an unannounced inspection. Beech Court Nursing Home is registered to provide support and accommodation for up to 26 older people. At the time of the inspection there were eight people living at the service some of whom were living with dementia and required personal or nursing care.

As this service is registered for one person as the registered provider (‘the provider’) this permits them to also carry out the role of the Registered Manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. In addition to this the provider had appointed a manager (‘the manager’), however, the manager’s role and extent of their responsibilities were not clear.

Risk management procedures were not effective. For example, people at risk of developing pressure ulcers were not always protected from these risks. People’s pressure mattresses were not always set to correct settings and staff had limited guidance on how to use this equipment. Repositioning charts were not consistently completed.

Safe recruitment procedures were not always followed before staff were appointed to work at Beech Court Nursing Home. We have made a recommendation on safe recruitment procedures.

People’s information was not protected as records in relation to people’s care were not always kept confidential. Other records in relation to people’s care were not always consistently completed or up to date.

There was on-going maintenance and building work within the home grounds at the time of our inspection. Fire safety notices had been put in place, however, these were not always being followed. This meant people might not have been able to be evacuated safely and effectively. We notified the Fire Service regarding our concerns the same day of our inspection. People’s mobility equipment was not always stored in a way which kept it accessible in case of emergencies.

The manager and staff had a basic knowledge but did not have a good understanding of the Mental Capacity Act 2005. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Where people were thought to lack capacity to make certain decisions, assessments had not been completed in line with the principles of MCA.

The manager and staff did not fully understand their responsibilities under the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be deprived of their liberty for their own safety. Under the MCA the provider is required to submit a DoLS application to a ‘supervisory body’ for authorisation to deprive someone of their liberty. Where people were deprived of their liberty related assessments and decisions had not been carried out. We have made a recommendation about reviewing and embedding legal safeguards within the MCA.

People’s nutritional needs were met. However, people were not always given choices and did not receive their meals in a timely manner.

People had access to limited activities and stimulation opportunities. Activities were not always structured to people's interests. Staff did not always know how to best support people and what activities and changes to the support would suit the needs of people. Staff did not always engage with people in a meaningful way.

Beech Court Nursing Home had suitably qualified and experienced staff to meet people's needs. However, staff were not always deployed effectively as at times, people were left without support. Where required, staff involved a range of other professionals in people’s care.

The provider’s policies had not been reviewed or up

We inspected Beech Court Nursing Home on 11 June 2015. Beech Court provides nursing care for people over the age of 65. Some people at the home were living with dementia. The home offers a service for up to 26 people. At the time of our visit 10 people were using the service. This was an unannounced inspection.

We carried out an unannounced comprehensive inspection of this service on 16 December 2014. Two  breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to ensuring the equipment people needed was set properly and the suitability and safety of the environment. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Beech Court Nursing Home on our website at www.cqc.org.uk.

The manager had ensured where people needed pressure relieving mattresses that these were set in accordance with their individual needs. The manager carried out weekly audits to ensure pressure relieving equipment was set properly and was effective.

The provider and manager had systems in place to ensure the environment was safe and secure. People were protected from the risk of harm as safety systems implemented by the provider were followed.

We carried out this unannounced inspection on 16 December 2014.

Beech Court Nursing Home provides nursing care for people over the age of 65. The home can accommodate up to 26 people and at the time of our visit 12 people were using the service, some of whom were living with dementia.

We last inspected in May 2014 we found two breaches of regulations in relation to records, the management of medicines and quality assurance systems of the provider. At the inspection in December 2014 we found the provider had taken action to rectify these concerns.

There wasn’t a registered manager in post at the service because the provider is not required to have one. However, the provider had recruited a manager who they planned to support through the registration process. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Areas of the home were undergoing maintenance at the time of our inspection. While health and safety notices had been put into place, these were not always being followed. People may not have been able to be evacuated safely and effectively. People’s mobility equipment was not always stored in a way which kept it clean and safe to use.

People were not always protected from the risks of pressure area damage. Pressure relieving equipment was not always set up in accordance with people’s needs and staff had limited guidance on how to use this equipment.

Staff had knowledge of safeguarding processes, the Mental Capacity Act 2005 (MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time) and Deprivation of Liberty Safeguards. The service ensured where people could not make specific decisions, best interest decisions were conducted and respected.

People received their medicines when they needed them and as prescribed. The home had audits in place to identify any concerns and ensure people were protected and lessons were learnt from concerns.

People enjoyed the relationships they had with staff and staff knew people, their needs and preferences. People were cared for by skilled care and nursing staff. People told us they were treated with dignity and respect and staff supported people with kindness and patience.

People’s needs were documented and these were reviewed and updated monthly or more frequently if needed. The management team acted upon feedback from people and their relatives. Feedback was used to inform changes to the service people received.

A new management team had been recruited by the provider. There were clear goals about developing the service people received. However, these plans were still being developed and we could not see the full impact of these audits.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

As part of this inspection we followed up on a number of areas of non-compliance from our last inspection in February 2014. These concerns related to the care and welfare of people using the service, management of medicines, supporting workers, quality assurance and records. As part of our last inspection we fined the provider for continued mismanagement of medicines, and issued two warning notices regarding assessing and monitoring the quality of service provision and records. We noted that at this inspection the provider had taken significant action.

On the day of our visit 13 people were using the service. They were supported by a combination of three care workers, a chef and a nurse. We spoke with three people who used the service and three relatives. We also spoke with a nurse, three care workers, a chef and the provider. Two inspectors carried out this inspection. The focus of the inspection was to answer five key questions;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Although improvements had been made the service was not completely safe. Following our last inspection we fined the provider because people’s medicines were not being managed safely. At this inspection we saw that the service had taken action, however there was still need for improvement. We noted that people’s medicines were stored securely but were not always administered as prescribed.

People were protected from the risk of malnutrition and dehydration. Care staff completed food and fluid charts where they had concerns over people’s well-being. Care plans had also been updated to reduce the risk of people receiving inappropriate care and treatment.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. During our visit we noted that no one had a DoLS application and we did not see that anyone was having their liberty deprived. The nurse showed awareness of the DoLS and was aware of current legislation in this area.

Is the service effective?

Although improvements had been made the service was not completely effective. People told us they enjoyed being at the home and felt well cared for. People we spoke with told us they felt respected. One person said, “Everyone is kind, friendly and talks to me in a nice way.”

People’s views and experiences were taken into account in the way the service was provided and delivered. For example, one person told us, “they asked us about the meals and if we would like anything different on the menu. We made some suggestions and the menu changed.” This meant that people were encouraged and enabled to be involved in how the service was run.

Care workers had not been appropriately trained to carry out their roles. All care workers undertook a period of induction training before starting work. Whilst care workers felt supported they had not received appropriate training. We saw that senior staff had identified the training that was needed, however no plan had been implemented to address this.

Is the service caring?

We found the service was caring. People we spoke with were complementary about the home. One person said, "I’ve never been so well cared for. The girls do a brilliant job.” Another said, “I am so well looked after, everyone is so good and kind.” A relative told us "It's marvellous. The staff are gentle and reassuring. We have a good laugh, they pull mums leg in a gentle and nice way. I’ve said stick my name down I’m coming here.”

Care workers recognised and understood people's social and cultural needs. We heard care workers talking to people about their families and the occupations they had before retiring. One care worker told us, “I sat with a lady and her daughter and did their life history. It’s so interesting, I love it. We can then talk to people about the things they have told us.”

We observed that people were involved in a range of activities for example using a bat and balloon for physical exercise or completing jigsaw puzzles with care workers. Throughout our inspection the atmosphere was pleasant and we observed many positive interactions between care workers and people that were relaxed and friendly.

Is the service responsive?

We found that the service was responsive. For example, we saw that where people’s needs had changed staff took appropriate action. We noted that the service had sought the advice of tissue viability nurses to help manage or prevent pressure damage, and speech and language therapists (SALT) when they had concerns about people’s swallowing.

The care workers we spoke with were able to describe how people should be supported following guidance from SALT. We observed people being assisted with fluids in accordance with instructions in their care plan.

We noticed that incident and accident records noted that the service took appropriate action to manage the risks associated with incidents and accidents and ensure the health and welfare of people living in Beech Court Nursing Home. This included making referrals to occupational therapists for specific equipment.

Is the service well led?

We issued a warning to the provider that we would take enforcement action following our last inspection. This was because the service did not have appropriate arrangements for assessing and monitoring the quality of service provision, to help ensure people’s safety. The service was taking appropriate steps to improve the service and lead its development. However it is too soon to be able to see if these changes were embedded and sustainable. The provider had designated responsibility to a nurse to conduct management tasks. The service had implemented audits regarding medicines and care plans following concerns raised at previous inspections. The service monitored all incidents and ensured people’s welfare. However, but the provider may wish to note that they did not have an audit in place to identify trends or concerns.

Staff told us that they all felt supported. All staff had access to supervisions and felt they had appropriate direction from senior nursing staff.

The provider had implemented action plans following our last inspection and had identified their own concerns with the service. We noted that these concerns were acknowledged and appropriate action taken.

We carried out this visit because we had concerns about the care provided at previous inspections. In August and November 2013 we had issued warning notices telling the provider that action must be taken in relation to the management of medicines. We found during this inspection that some actions had been taken. However, these were not sufficient to ensure that medicines were managed safely.

In August 2013 we identified that people were at risk because equipment was not stored appropriately. At this inspection we found that the provider had taken appropriate actions to ensure that the environment was safe.

In November 2013 we had identified that people's records, relating to their care and treatment, were not always accurate, meaning people were at risk of inappropriate care and treatment as an accurate record of their needs had not been maintained.. During this inspection we found that sufficient action had not been taken to ensure records were maintained in a way that ensured people always received safe care and treatment.

We spoke with three people who were complimentary about the care they received and felt safe within the service. However, we found that people were not fully protected from the risk of inappropriate care and treatment as staff did not deliver care in line with people’s assessed needs. For example people were not always from the risk of developing pressure sores as staff did not follow people’s assessed needs.

Whilst staff told us that they felt supported, we found that staff did not always have access to appropriate supervision, appraisals and training.

The provider did not have systems in place to ensure the quality of the service they provided. The provider did not have appropriate systems to manage and act upon concerns raised by external agencies.

We inspected this service because we had received information that people with pressure sores were at risk. We were told that the management of pressure sores was not effective and that people were deteriorating. On the day of our visit we found that this was not the case. We were told that food was left out defrosting and that stored food was out of date. We were also told that staffing levels were dangerously low. We looked at the kitchen and the levels of care staff on duty and found no evidence to support the allegations. We were told fire doors were wedged open preventing them from closing in the event of a fire. On our visit we found one door wedged open. This was rectified when we mentioned it to a nurse.

There was only one person with a pressure sore at the home. We spoke with one nurse and two care workers. Everyone we spoke with demonstrated a good knowledge of the management of pressure sores. They were able to tell us what treatment the person needed, how often the person needed to be repositioned and why.

We asked to see the person’s care plan and repositioning records. We saw that this person's plan was appropriate and was being followed.

We found that the record keeping regarding repositioning this person was not completed consistently and we found gaps in the records. We also found that repositioning records were not sufficiently clear or detailed.

We looked at this outcome following non-compliance regarding management of medicines at the last inspections in November 2012 and August 2013. A warning notice was served following our inspection in August regarding the recording of the administration of medicines and the safe storage of medicines.

At this inspection we checked the arrangements for storing, handling, administration and recording of medicines. We looked in detail at the medicine records for six people living in the home.

Medicines were not kept securely. We found that there were appropriate arrangements for storing most medicines, including controlled drugs. However we found that the medication refrigerator, which is kept in an unlocked room, was not locked.

Medicines were handled appropriately. There were systems in place for the obtaining, administering and disposal of medicines.

Medicines were not safely administered. For five people we found that the records of medicines received into the home and the number of doses signed for on the medicine administration record (MAR) chart did not match.

Where medicines were prescribed as variable doses the actual amount of medicine administered was not recorded, therefore it was not possible to determine the actual medicine administered.

The registered provider told us that staff had not received refresher training in the safe handling of medicines since our last inspection.

This was a scheduled visit. However we also followed up on areas of non-compliance noted at a previous inspection.

At the time of our visit there were 19 people living at the home. The manager, one nurse and three care workers were on duty. We spoke with six people and two relatives about consent. One person told us, “They always ask before they do something”. The provider had made improvements regarding this outcome.

We saw that care workers treated people with warmth and cared for people at a relaxed pace. However, the provider may like to note that we observed some care workers did not always engage or acknowledge people.

We saw the home was clean and there were processes in place to maintain a clean environment. We noted that the provider had made improvements regarding this. However, we saw that hoists were not stored properly and were left in unsuitable places creating trip hazards.

The provider had not made all the required improvements regarding the management of medicines. The provider did not have appropriate systems in place for the prescription and administration of boxed medications. Medicines were not always kept safely.

People we spoke to told us they felt able to raise concerns. One person told us, “If anything is wrong I can tell them”.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate records were maintained.

We spoke with two people using the service, six members of staff, two relatives, a visiting physiotherapist and the hairdresser. People using the service told us they were happy with the care they were receiving. When talking about choices one said “I eat in my chair in the lounge, that’s what I prefer. The chef is great, he always asks what I want and when”. One relative said “I often see a care assistant sat on the edge of a resident’s chair, talking to them, they seem to know all about the residents and their lives before they came to live here.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

We spoke to one member of staff who said they were provided with the support and training they required. We spoke to another who had worked for the service for some months, but who had not received any training.

We found shortfalls in areas of cleanliness and hygiene, some record keeping and the management of creams and ointments. There were shortfalls in the service being able to demonstrate that people who lacked mental capacity were being fully protected under the Mental Capacity Act 2005. We did not find any evidence that would suggest that people's care needs were not being met but opportunities for social activities and social interaction were limited for some.