Beech Tree House

Updated 11 November 2020

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

Two inspectors carried out visits on 11 and 23 September 2020 and one inspector made phone calls to staff and people’s relatives to gain their feedback.

Service and service type

Beech Tree House 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.

Notice of inspection

The first day of the inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with one person who used the service and six relatives about their experience of the care provided. We spoke with 13 members of staff including care workers, a domestic worker, two assistant regional directors, the registered manager, deputy manager and a senior care worker. We observed care provided by staff to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included parts of eight people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. A number of these records were provided to us electronically to reduce the amount of time inspectors spent on-site.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at Positive Behaviour Support systems and records, training data, care records and other management records. We spoke with two professionals who regularly visit the service and received written feedback from a further three professionals.

Updated 11 November 2020

About the service

Beech Tree House is a residential care home providing personal care for up to eight adults with learning disabilities and/or autism. The service is provided over two floors. Each person has their own bedroom and en-suite, with shared areas such a lounge, dining room, bathroom, quite room, sensory room, and activities room. People had access to a garden area at the rear of the property.

Services for people with learning disabilities and or autism are supported

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to eight people. Eight people were using the service at the time of our visit. This is larger than current best practice guidance. Environmental factors and the way the service was arranged sometimes impacted the ability to provide truly person-centred care.

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

The service did not always establish or implement robust systems to protect people from the risk of abuse. We found concerns in relation to the management of people’s finances and people were not always protected from the risk of abuse. The registered manager had reported recent safeguarding allegations to the local safeguarding authority as required and taken action to prevent reoccurrences. Hazards and safe measures were not always clearly identified in people’s care records in response to incidents and staff did not always fully understand risks to people. The general fire evacuation plan was not up-to-date or accurate. Water safety systems were not routinely implemented and control regimes were not effective in controlling the presence of Legionella bacteria. Other health and safety checks and compliance certificates were in place to promote safety.

Medicines were not always managed safely. We found issues with medicines records and stock rotation which placed people at increased risk of not receiving their medicines as prescribed. Infection prevention and control policies and procedures were not always fully implemented by the service, which placed people at increased risk of infection. Improvements had been made to the cleanliness of the environment. Recruitment checks were completed to make sure staff were suitable, however, risk assessments surrounding checks of new staff were not always implemented. Staffing levels had improved to meet people’s needs.

Governance systems did not always identify or manage risk effectively. For example, provider medicines and financial audits did not identify the concerns we found. The provider’s policies and procedures were not always robust or implemented by the service. Improvements had been made to the culture of the service. Relatives and staff consistently reported the new registered manager had made a positive impact upon people’s quality of life. Relatives reported the service was more open and they felt comfortable raising concerns with the provider.

Staff training and supervision had improved, however, staff were not always competent to meet people’s needs safely. The principles of the Mental Capacity Act were not fully understood or appropriately applied by the service. This meant people did not always receive appropriate support in their best interests. Assessment of people’s needs were not comprehensive to ensure the environment and compatibility of people using the service was suitable. Noise levels had an impact on people’s wellbeing. We found fresh fruit and vegetables were not available to people on day one of our inspection, which was immediately addressed. The registered manager had made improvements to the menu and monitoring of people’s nutritional intake. People were supported to access a range of healthcare professionals to meet their needs.

In general, we observed staff interactions with people were positive and engaging. We raised concerns with staff referring to people as “good”, which was not respectful which the management team agreed to address with staff. Relatives told us, “Staff appear helpful and kind. Happy with attitude of staff and management” and “[their family member felt] safe, secure and understood.” Staff had received specific communication training and we observed staff use people’s preferred methods to involve them in day-to-day choices. Relatives had the opportunity to contribute to people’s care planning and felt more involved by the service.

The provider’s care plan system aimed to identify people’s preferences and diverse needs including protected characteristics such as religion and sexual orientation. However, information recorded in care records did not always provide clear guidance about how to meet people’s preferences. The registered manager had identified that care plans needed to be reviewed. They had started to make some improvements where they had spent time with people to get to know them and monitored staff support. Systems were in place to make sure information was adapted using people’s preferred communication tools to enhance understanding and involvement. Staff received training in methods to promote people’s skills and independence. We saw staff apply this in practice when supporting people.

The service did not always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons. People were not always supported by staff who had the skills or confidence to use their preferred methods of communication. This meant people were not fully involved to make choices about their care and support or the way the service was run.

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 inadequate (published 24 January 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made and the provider was still in breach of four regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 14, 18 and 21 November 2019. Breaches of legal requirements were found. Enforcement action we proposed was reviewed in consideration of the COVID-19 pandemic and withdrawn due to intelligence the service was making improvements. The provider completed an action plan after the last inspection to show what they would do and by when to improve person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting upon complaints, good governance, staffing and notifying CQC of certain events.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to all the Key Questions; Safe, Effective, Caring, Responsive and Well-led which contain those requirements. The overall rating for the service has changed from Inadequate to 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 Tree House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified continued breaches in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, need for consent and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Requires improvement’. However, the service will remain in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated impro