Beech Haven

Updated 10 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by 2 inspectors, a member of the CQC medicines inspection team and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

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

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We looked at all the information we held about the service including feedback from the local authority and notifications of significant events. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with 9 people who used the service. We spoke with 6 members of staff including the registered manager, and care workers. We looked at 3 staff files in relation to recruitment and staff supervision. We reviewed a variety of records relating to the management of the service, including policies and procedures. We looked at records used by the provider to manage the service which included the care plans for 4 people, records of audits and checks, and management records. We conducted a full tour of the environment, which included an audit of infection prevention and control. After the inspection we continued to seek clarification from the provider to validate evidence found. Relatives gave us feedback about the service.

Updated 10 May 2023

About the service

Beech Haven is a care home for up to 30 older people. The service is a family run business and they have managed the home for over 30 years as a partnership and is now a limited company. The home is a converted building on a residential street in the London Borough of Ealing. At the time of our inspection, 24 people were using the service. Some people were living with dementia.

People's experience of using this service and what we found

The provider did not always have effective systems in place to safeguard people from risk or manage medicines safely.

The provider had quality assurance systems in place to monitor and manage the quality of-service delivery. However, these were not always effective as they had not identified where improvement were needed. There were infection prevention and control policies in place, however the provider did not always follow these. We have made a recommendation that the provider follow national guidance for infection prevention and control.

We found that the environment was not always dementia friendly, and we have made a recommendation about this.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We have made a recommendation that the provider consider current guidance and implementation of the Mental Capacity Act 2005 (MCA).

People at the service were happy living there. Their needs were being met and they were able to make choices about their care.

Safe recruitment procedures were followed. Staff knew how to respond to possible safeguarding concerns. The staff were happy working at the service they knew people well.

The management team were the family who owned the care home. They worked with staff providing support for people using the service. They had a good knowledge of the individual needs of the people who were living there and had good relationships with them and the staff. People using the service and staff told us they felt managers were approachable.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 5 October 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now

met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective,

and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the

overall rating. The overall rating for the service has remained requires improvement. This is based on the

findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for

Beech Haven on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and good governance. We have also made recommendations in relation to infection control and prevention, creating a more dementia friendly environment and further implementing the principles of the Mental Capacity Act 2005.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.