9 March 2023
During an inspection looking at part of 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.