Beaufort Hall Nursing Home

Updated 12 May 2022

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 completed by one inspector.

Service and service type

Beaufort Hall Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Beaufort Hall Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service 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. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. 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 used information gathered as part of our monitoring activity that took place on 22 March 2022 to help plan our inspection. We also reviewed information we had received about the service since the last inspection, including the provider’s action plan.

We also 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

We spoke with the registered manager, deputy manager, facility manager, two care staff and five people that lived in the home. We observed how staff interacted with people. We considered all this information to help us to make a judgement about the home. We reviewed a range of records relating to the management of the home, staff recruitment records, three people’s care and a sample of medicine records.

We continued to seek clarification from the registered manager to validate evidence found after the site visit. We looked at training data and quality assurance records. We spoke with four relatives and about their experience of the care and support and contacted a health professional who regularly visited the service.

Updated 12 May 2022

Beaufort Hall Nursing Home provides accommodation, nursing and personal care for up to 33 people, some of whom are living with dementia. It is also registered to provide the regulated activity of treatment of disease, disorder and injury. At the time of this inspection there were 26 people living in the service.

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

People and relatives spoke positively about the care and support that was in place. People told us they felt safe and staff were attentive to their needs.

There had been workforce pressures within the service when on occasions the home was staffed below expected numbers due to staff absence. The registered manager and the team had tried to cover the shortfalls including contacting staff agencies.

Staff received training on how to keep people safe and what to do if they had concerns. Medicines were administered safely. Since the last inspection, the provider had made improvements to their recruitment processes to ensure appropriate checks had been carried out before staff were employed.

The provider was following government guidance to prevent people and visitors to the home spreading COVID-19 infection. The provider kept in touch with relatives through regular emails, telephone calls and newsletters. Visits to the home were promoted and in line with government guidance. We observed good infection control measures were in place. The home was clean and free from odour. Staff were wearing appropriate personal protective equipment (PPE).

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were involved in their care and consulted on how they wanted to be supported. Regular meetings were held with people to gain their views on the service and make improvements. People were consulted about what they wanted to eat.

There were systems in place to monitor the quality of the care and support. The provider regularly visited the service to drive improvements and support the registered manager and the staff. Improvements had been made to ensure incidents, accidents and allegations of abuse were reported in a timely manner in response to a breach of regulation found at the last inspection.

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 12 August 2020) and there were breaches of regulation in respect of ensuring robust recruitment processes were followed and failure to notify the Commission of safeguarding concerns.

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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was prompted by a direct monitoring review we held about this service, concerns were raised about staffing, risk management, accuracy of records and governance arrangements. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from this concern.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Beaufort Hall Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.