We inspected Beechdale House Care Home on 12 July 2017. The inspection was unannounced. Beechdale House is situated in Nottingham City. The service is registered to provide accommodation and nursing for a maximum of 40 older people and people living with dementia. There were 25 people living at the service on the day of our inspection visit.

Beechdale House Care Home is required to have a 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 home is run. At the time of our inspection a registered manager was in post.

People and their relatives told us that they felt staff provided safe care and support. Staff were trained in adult safeguarding procedures and knew what to do if they considered someone was at risk of harm or if they needed to report concerns.

There were systems in place to identify risks and protect people from harm. Risk assessments were in place but not all had been reviewed at the frequency required. Accidents and incidents were recorded and reported by staff. The registered manager analysed these to ensure appropriate action had been taken to protect people, and to consider if there were any themes or patterns that required further action. Contingency plans were in place to support staff to provide a safe service in the event of an untoward incident affecting the service. Staff did not always use safe moving and handling practice when supporting people with transferring.

Whilst some concerns were made about staffing levels these were found to be sufficient on the day of our inspection visit. Safe recruitment procedures were in place and followed. Medicines were given to people on time and as prescribed. Some concerns were identified with liquid medicines and topical creams that were not labelled with their date of opening. When medicines were handwritten on the medicine administration records there were not always two staff signatures to indicate they were checked for accuracy of transcription.

People were supported effectively by staff that had received an induction, ongoing training and support. Policies and procedures were in place to guide staff in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Some people had a DoLS authorisation in place or the registered manager had submitted application where appropriate. Staff had received appropriate training and understood the processes in place for ensuring decisions were made in people’s best interests. People and or their representative where appropriate, had given consent to their care and treatment.

People received sufficient to eat and drink and their nutritional needs had been assessed and planned for. People were appropriately supported with their eating and drinking needs if required, choices were offered and respected, and independence encouraged as fully as possible.

The service worked well with visiting healthcare professionals to ensure they provided effective care and support. When concerns were identified about people’s healthcare needs, appropriate action was taken to support people’s health and well-being.

Staff were kind and caring, they knew people well, and they supported people on the whole in a dignified and respectful way. Staff on the whole acknowledged and promoted people’s privacy. People felt that staff were understanding of their needs and that they had developed positive relationships with them. Information about an independent advocacy service was available for people should this support have been required.

People and or their relatives where appropriate, were involved in the assessment and review of their needs. Care plans informed staff how to support people and were on the whole personalised to people’s

We carried out an unannounced inspection of the service on 12 July 2016.

Beechdale House Care Home provides accommodation and nursing care for up to 40 people. In addition to nursing needs some people were living with dementia. At the time of our inspection 26 people were using the service and one person was in hospital.

At the last comprehensive inspection on and 1 and 2 March 2016 this provider was placed into special measures by CQC. A breach of 12 legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to:

• providing care that was appropriate, safe and met people's needs,

• safeguarding people from abuse and improper treatment,

• having appropriate infection control prevention and measures in place,

• providing sufficient numbers of suitably qualified, competent and skilled staff,

• treating people with dignity and respect,

• providing person centred care,

• safe management of people's medicines,

• maintaining the premises and equipment,

• assessment and monitoring of the service,

• providing staff with appropriate support, training, supervision and appraisal,

• having a process to receive and act on complaints,

• ensuring all conditions of registration with the CQC were being met.

During this inspection we found that some improvements had been made and these breaches in regulation had been met. However, we identified further work and time was required for improvements to fully embed and be sustained.

Beechdale House Care Home is required to have a 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. At the time of our inspection the registered manager was no longer working at the service. A new manager was in post and they were in the process of submitting their registered manager application. We will monitor this.

Improvements had been made to how people who used the service were protected from abuse and avoidable harm. Where concerns had been identified the provider had taken correct action in informing the local authority responsible for investigating safeguarding’s and had informed CQC. Staff had received adult safeguarding awareness information and further training had been planned for.

Risks associated to people's individual needs had been assessed and planned for. We found the information provided to staff of how to manage known risks were variable. Accidents and incidents were recorded and action had been taken to reduce risks from reoccurring. However, the provider lacked systems and processes that analysed events that would provide oversight of any patterns, trends and themes.

Improvements had been made to the premises and equipment. The premises were found to be safe and equipment had been serviced and new clinical equipment purchased.

The cleanliness of the service had improved. Additional domestic staff had been employed and cleaning schedules reviewed and improved. The service had recently had an infection control audit completed by the local clinical commissioning group. The provider had developed an action plan in response to the shortfalls identified.

The provider had completed appropriate recruitment checks before staff began work to check their

suitability. A dependency tool had been introduced that determined what staffing levels were required. Staffing levels had increased to ensure people’s needs and safety were appropriately met.

The management of medicines had improved, but no protocols were in place for people that had prescribed medicines to be taken as required.

The support available to staff had improved. Staff received an induction to support them to understand their role and responsibilities. Staff had received opportunities

This inspection took place on 1 and 2 March 2016 and was unannounced.

Beechdale House Care Home provides accommodation and nursing care for up to 40 people. At the time of our inspection, 30 people were using the service. The home is set on a main road and has two storeys. Two of the rooms were shared, and the rest were single rooms. There were communal bathrooms and toilets. There is one lounge and a separate dining room.

At our last inspection of the service on 10 February 2015 we identified that there was a breach of Regulation 13 of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2010. The registered person did not have suitable arrangements to protect service users against the risks associated with unsafe management of medicines. At this inspection we found that further work was required in this area.

There was a registered manager in post at the time of our inspection. 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.

People were not always protected from the risks of harm or abuse. Staff we spoke with knew what to do if abuse was suspected, but we were not confident that the service always made referrals to the local authority in a timely way.

Risks had not always been managed to keep people safe. Risk assessments had been completed but these were not always acted upon, which meant people could be left at risk of harm.

We were not confident that people who required medication received this as the prescriber had intended. Not all staff who administered medicines had completed an annual assessment to assess their competency in the area. Medication audits were not being regularly done to check any areas that required improvement. This meant that there was a greater risk that errors would be made.

Action had not been taken in a timely manner to ensure the environment was maintained in a safe way. Substances and equipment were accessible that could have posed a serious risk to people’s safety. There was no schedule of servicing for some medical equipment, and we had concerns about fire safety, the lack of an up to date gas check certificate and electrical certificates. This meant we were not sure people were safe in the environment of the service.

Two recruitment records we looked at did not contain the mandatory Disclosure and Barring checks (DBS).The provider told us they were agency workers but not all of the files we checked were agency workers. One staff file had handwritten references on scraps of paper from an unidentifiable person. This meant we could not be sure that all staff had been safely recruited.

The provider was not using any tool to help them decide on safe staffing levels. There were insufficient staff to meet people’s needs and manage risks.

The environment was not clean and this increased the risk of infection spreading. There were insufficient cleaning staff on duty. Chairs and furniture were not always clean. There was a lack of hand washing signs and hand gel dispensers.

The training given to staff was not always sufficient to ensure people had the skills and knowledge they required to do their job. This was because staff training information was not available for all staff, and not all staff had undertaken training that was required. Some staff were not receiving regular supervisions.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was not acting in accordance with the MCA, including DoLS. The provider had referred all people using the service for a DoLS, when not all of the people lacked capacity. There was a person already subject to a DoL

This inspection took place on 10 February 2015 and was unannounced.

We last inspected Beechdale House Care Home on 22 January 2014. At that time it was not meeting six essential standards. We asked the provider to take action to make improvements in the areas of meeting people’s needs, cleanliness and infection control, safety and suitability of premises, requirements relating to workers, assessing and monitoring the quality of the service and records. We received an action plan dated 8 March 2014 in which the provider told us about the actions they would take to meet the relevant legal requirements. During this inspection we found that the provider was meeting these legal requirements. However we identified a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Beechdale House Care Home provides accommodation and nursing for up to 40 people who have nursing or dementia care needs. There were 27 people living in the home at the time of our inspection.

A registered manager was in post at the time of our inspection. 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.

Staff were knowledgeable in how to safeguard people from abuse. They had attended relevant training, which helped them protect people from abuse.

The provider had a robust recruitment process to ensure they employed qualified and skilled staff to meet people’s needs.

People received their medicines as prescribed and in a safe way. However, the medicines were not always stored safely. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff were aware of the Mental Capacity Act 2005 (MCA), and Deprivation of Liberty Safeguards (DoLS). The provider made suitable arrangements to ensure people who lacked the capacity to make their own decisions were appropriate supported. Mental Capacity assessments had been implemented for all the people living in the home.

Risk assessments had taken place to ensure people’s needs were met. Staffing levels were assessed and monitored to ensure they were sufficient to meet people needs.

People received suitable support to help them eat and drink independently. People received sufficient amounts to eat and drink. Staff were knowledgeable about people’s dietary requirements to ensure they received a nutritional diet. Improvements are needed to ensure that dietary advice is followed for everyone who lives at the home.

People felt that their needs were met by knowledgeable staff who understood their individual care needs. Staff completed an appropriate induction when they first started work at the home. relevant training had been undertaken by all staff to ensure people were cared for by suitably skilled and qualified staff.

People felt their privacy and dignity were respected. staff interacted with people they were caring for in a calm and respectful manner. People’s needs were assessed and monitored to ensure they maintained good health and wellbeing. The manager consulted other professionals and followed advice when required to ensure people’s changing needs were met.

People were encouraged to be involved with their care and how the home was run. Complaints and concerns were dealt with in a timely manner. People felt able to raise concerns and knew who they should raise them with.

The manager was open and approachable. They had appropriate systems in place to gather, record and evaluate information about the quality of the service.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We spoke with three people using the service and three relatives. We also spoke with a visiting professional.

All three people told us they were very happy and settled living at Beechdale House and staff looked after them well. One person said, “The staff are pleasant, they are on hand if you need anything. I enjoy walking around, going out and socialising with others.” Another person said, “I am happy and settled living here, I enjoy it and the staff are nice.”

However we found care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

We also found there were ineffective systems in place to reduce the risk and spread of infection. Nevertheless people spoken with told us they felt that the home was clean and tidy. One person said, “It’s kept clean.” Another person said, “My room is nice, it is kept clean and tidy.”

One relative said, “”There is no smell, it’s kept very nice.”

Although the provider continued to improve the environment we found they had not fully taken steps to provide care in an environment that was suitably designed and adequately maintained.

We spoke with two people about the environment and asked them if they felt it was maintained. Both of them told us they felt the environment was well maintained. One person said, “It’s mostly well maintained.” Another person said, “I have a nice room, it is kept nice and it has just been redecorated.”

We saw that effective recruitment and selection processes were not always in place.

Although there were some gaps in staff training we saw they were being offered training to develop their knowledge and skills in relation to the job role they were to perform.

The provider was monitoring the quality of care being delivered but they were unable to fully demonstrate that there was an effective system in place to monitor the quality of the care and support being provided to people and make the necessary improvements.

We saw some records were not always accurate and fit for purpose and had not always been stored securely.

When we visited the service in September 2012 we found some improvements were needed in relation to this outcome. The registered provider sent us an action plan telling us what improvements they would make and by when. When we visited the service this time we found the required improvements had been made.

Last time we visited we had some concerns about the way some members of staff referred to people and about staff not noticing when a person’s dignity was compromised. This was not best practice and we asked for improvements to be made. During this visit we saw the provider had met with staff and reminded them of the importance of supporting people to maintain their dignity. We observed staff interactions with people and we saw staff were patient and respectful and people were addressed appropriately.

We spoke with two people using the service about their privacy and dignity being respected by staff. Both people told us they did not have any concerns in relation to this and one said, “Staff talk to me very nicely. They have never been disrespectful.”

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an “expert by experience” (people who have experience of using services and who can provide that perspective).

To help us understand people's experiences we used the Short Observational

Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us

understand the experiences of people who could not talk with us. We chose to use

SOFI in the main dining room on the ground floor, because this was where most people ate their lunch.

People who use the service understood the care and treatment choices available to them. For example we heard staff explaining what they were going to do to support people prior to giving care or support. Where people expressed they did not want this support, staff respected this. Where people were transferred using a hoist from an armchair to wheelchair in preparation for lunch, staff explained fully what they were going to do throughout the transfer. All five people we spoke with told us they were consulted by both staff and management on their daily welfare and satisfaction with standard of care. However none of the people we spoke with knew about their individual care plan.

People were supported to be able to eat and drink sufficient amounts to meet their needs.

During our SOFI observations staff were seen to encourage one person who we knew to be nutritionally ‘at risk’ to eat more. They gave the person a soft diet, in line with instructions from the person’s care plan, and gave them support and encouragement throughout the meal. The result was that the person finished all of their meal.

Our observations of the meal were generally positive. However we observed two examples of people not receiving support with their nutrition and/or hydration in a timely manner. We also saw some practice which did not promote people’s dignity.

We observed staff interacting with people who were seated in the lounge areas. They appeared to have a good knowledge of individual likes and dislikes. Attentive care was given at the speed of the individual’s abilities with good explanations and reassurance.

All five people we spoke with told us they felt safe in the home. One person we spoke with said, “Staff treat me very well, they are very good. I can’t fault anybody, they are all nice.”

People using the service and their relatives spoke positively about the quality of staff and care. One person told us, “You only have to ring the bell and they (staff) come” and another said, “The home has been without a manager for a while but the staff do very well”.

All of the five people we spoke with told us they received unhurried care with one person telling us, “I always take my time and staff are very patient with me.”

People’s personal records including medical records were accurate and fit for purpose. We found records were kept securely and could be located promptly when needed.

People told us that care staff involved them in their care, treatment and support programme and they received input and treatment from other health care professionals such as general practitioners, opticians, chiropodists and specialist nurses.

People who used the service and their relatives told us that they were encouraged to undertake a range of social activities within the home and within the community.

People told us that they felt safe in the home. The relatives of people who used the service said that they felt that the staffing levels were sufficient to meet people’s needs and maintain their safety. People felt the staff had the right qualifications, skills and knowledge to perform their duties safely.

People who used the service and their relatives told us that they were provided with the opportunity to comment on the quality of service provision at residents meetings and were also able to discuss any issues which were important to them.