This inspection was carried out on 12 and 27 September 2018 and was unannounced. We visited Bushey House Beaumont on 12 September 2018, however received further information of concern following the inspection. On 27 September 2018 we followed up these concerns with telephone calls to people's relatives. At their last inspection on 15 December 2015, the provider was found to be meeting the standards we inspected. We rated the service overall as good. At this inspection the service overall rating had changed to requires improvement. At this inspection we found breaches of regulations 12, 16 and 17 of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. This was because people experienced delays receiving their care and medicines, complaints were not responded to and a system of governance was not effectively managed.

Bushey Beaumont 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.

Bushey Beaumont accommodates 62 people across two separate units, each of which have separate adapted facilities. At the time of the inspection 44 people were living in the home.

The service did not have a registered manager in post. The previous manager left in February 2018. A new manager had been appointed two weeks prior to this inspection and would apply to register as the manager following this 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 consistently supported to live in a safe environment. People’s call bells to request assistance were not responded to promptly and staffing was not effectively monitored or deployed. People did not receive their medicines as prescribed. Staff were aware of the risks to people’s health and wellbeing and measures were in place to manage these safely. People were supported by staff to be safe living in the home. Staff were aware of when to report any concerns about people’s safety. People lived in a clean and well-maintained environment and were cared for by staff who followed infection control procedures.

People’s consent to care had not consistently been sought in line with the legal requirements where they lacked the capacity to provide consent. People’s dietary needs were not always well managed. However people were supported appropriately by staff to eat and drink sufficient amounts. A range of health professionals supported people’s health needs when required, however follow up appointments were not always made. Staff received training in key areas to support them in their role, and staff received appropriate support from their line manager.

Complaints were not responded to in a timely manner and some people and relatives had lost confidence in raising their concerns. People’s social needs were not always met, particularly when people chose to not participate in group activities.

The service had undergone a period of instability whilst recruiting a permanent manager. People and relatives did not all think the service was well managed. However, they were positive about the recent appointment of the manager. Systems and processes to monitor and improve the quality of care had not been effectively managed. Notifications of significant incidents had not been submitted in a timely manner as required.

People’s dignity and privacy was mostly met and staff interactions were kind and considerate. Care staff supported people patiently and sensitively and enabled people to remain independent.

The service had undergone a period of instability whilst recruiting a permanent manager.

The inspection took place on the 15 December 2015 and was unannounced. The service is registered for 60 people. On the day of our inspection there were 52 people living at the home.

Bushey House Beaumont is registered to provide accommodation for people who require nursing or personal care. It can also provide diagnostic and screening procedures and carry out treatment for disease, disorder or injury.

There was a registered manager in post. 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 received care that met their needs and staff knew them well. People were involved in planning their care and the manager and staff valued their views.

Staff had been trained and were able to recognise any signs of abuse and knew how to report concerns. People were looked after by sufficient numbers of staff to meet their needs safely at all times.

People were encouraged and supported to live as independently as they could. Risk to people`s health, safety and wellbeing were identified and actions were put in place to manage and mitigate the risks to keep people safe.

There was a robust recruitment procedure in place to ensure that staff employed were suitable to work in a care setting. Staff employed at the service had completed an induction when they commenced working at the home and had received on-going and refresher training relevant to their roles.

People`s medicines were administered safely by staff who was appropriately trained. There were appropriate systems in place for the safe storage of medicines and we saw that medicine recording records were completed correctly.

People who used the service felt they were treated in a caring way and with kindness. People’s privacy and dignity was respected by staff and each other. People were supported to maintain their health and wellbeing.

The provider carried out weekly and monthly audits and any issues found were actioned and followed up to ensure the service improved and the shortfalls were corrected.

The Mental Capacity Act (2005) provides a legal framework for making particular decisions on behalf of people who may lack mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. Where they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS)

We checked whether the service was working in line with the principles of the MCA and whether any conditions on authorisations to deprive a person of their liberty were being met. We found that most people living at the service were able to make their own decisions and those who were unable to had their capacity assessed. The manager and staff understood their roles in relation to DoLS.

The provider had a policy and process for dealing with complaints and concerns. There were some quality monitoring processes in place and these were being developed by the manager. People’s views had been sought regarding the quality of the service.

The inspection team was made up of two inspectors. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We spoke with five people who used the service and they all said that they felt safe living at the home. We saw evidence that risk assessments had been undertaken to help minimise risks to people living at the home. The home had a complaints policy and procedure in place and people we spoke with all knew how they could make a complaint.

The registered manager had undertaken an unannounced night spot check on the night prior to our inspection as part of a planned programme of out of hour’s visits to ensure that the home was safe and that people were being cared for appropriately.

Is the service effective?

We looked at the care records of six people who lived at the home. We found these provided details of what care and support people needed. The care plans detailed the type of support people required and when we spoke with staff they were able to demonstrate that they had a good knowledge of the needs of the people in their care.

Consent had been obtained from people and/or their relatives for the care and treatment which was documented in peoples care plans. However the provider consent policy did not contain any information on how people could withdraw their consent.

Is the service caring?

During our inspection we saw that staff were supporting people to undertake a range of tasks. We saw that staff involved and treated people with compassion, kindness, dignity and respect. Staff were kind and patient with people and people told us that most of the staff “were lovely”.

Is the service responsive?

By responsive, we mean that services are organised so that they meet people’s needs. We found that people’s needs were being met in accordance with their assessed needs. There were arrangements in place to review people’s needs and risk assessments so that they could continue to be responsive to people’s changing needs.

Is the service well-led?

The service had a robust quality assurance system in place. The leadership, management and governance of the organisation assured the delivery of high-quality person-centred care. It supported learning and innovation, and promoted an open and fair culture.

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We found that generally people looked comfortable and relaxed in their surroundings. We observed people’s bedroom doors being open and found that this was not always their choice. People we spoke with told us they felt “safe” living at Bushey Beaumont. A person we spoke with described living in the home as ‘lovely.’ Another person we spoke with said of the home “It’s very good, I admire it very much. The people are excellent. Very good they do a wonderful job. I like it here.”

During our inspection we found that the home did not always obtain peoples or their relatives consent for care and treatment.

We saw evidence that the home had an efficient recruitment process which ensured that staff were suitable and qualified for their roles. However, not all staff had had regular supervision or annual appraisals.

During our inspection visit we observed that medication was appropriately stored and any medication that required storage at cooler temperatures was stored in the fridge. The fridge temperature was recorded daily. However we noted when we checked that some medication which was stored in the fridge had expired.

We saw evidence that the chef provided choices of food and drink for people to meet their diverse needs, making sure the food and drink which was provided was nutritionally balanced and supported people’s health.

We were concerned about record keeping as some records were not readily available for inspection and could not easily be located when requested.

We spoke with five people who used the service and one relative of a person who used the service.

One person said, “All of the nurses and carers are good.” They explained, “If I need them, I will call them.”

Another person said that the staff were, “Very nice. They know how to look after me.”

A relative of a person who used the service said that they were “happy” with the care that their relative received.

The people who use the service told us that they enjoy living at Bushey House. They said that the staff are 'very good', competent and able to support their needs in the way the residents choose. People said the staff had looked after them well during the recent bad weather and that they had not noticed any staff shortages at this time.

People told us that they found that the food provided was of a very high standard and there was a wide choice offered at all meal times. Two residents we spoke with said that, although snacks were always available, they rarely needed these.

Those residents we spoke with were happy with the manner in which, the home is furnished and maintained. People said it is always kept very clean and warm and that it is a comfortable and pleasant place in which to live.

We conducted three visits to Bushey Beaumont House and we had mixed responses to how people found living there.

During our visit on 27 June 2011 people we spoke with who were ambulant and able to care for themselves told us that they had a very good experience living there. However those people who were more dependent on staff to assist them in their daily lives were anxious about the amount of time they have to wait for assistance.

By the time of our second visit on the 13 October 2011 the people were more positive about their daily lives in the home as they told us that many of the issues they had raised had been addressed by the management team.

Our final visit was conducted on the 28 November 2011 to look at how the medication was administered the people we spoke to at the time of that visit were happy with their care and how their medication was administered to them.