Beechdale House Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified a breach of the legal regulations. Quality management systems were not effective and although the provider was involved daily with the service, their quality oversight of the service was poor. We saw a lack of evidence at our assessment that the provider and registered manager had identified the significant risks we identified. We were not assured the provider would make and sustain the required improvements at the service. There was a lack of clear and effective governance, management and accountability arrangements. There were shortfalls in the robustness of the arrangements for the confidentiality of data and record storage systems. For example, we found multiple occasions where personal data was left unaccompanied in a communal space which was accessible to anyone who was present in the building. Information was not used effectively to monitor and improve the quality of care. Notifications were consistently submitted to external organisations as required. Staff we spoke with understood their role and responsibilities. People and their relatives were positive about the availability of the registered manager if they wished to raise concerns and told us they felt they would be addressed if they did so.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although all of the staff we spoke with told us the provider carried out regular visits to the service, the systems and processes to monitor quality and safety were not fully effective in protecting people from the potential risk of harm. The provider had not identified all the shortfalls in the expected care standards found during this assessment.

The provider had failed to do all that was reasonably possible to assess, manage and mitigate risks to people's health and safety in relation to the risk of poor infection control practice, environmental risks, medicines management, staff skills and knowledge and risks related to people's identified health needs.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.