11 December 2020
During an inspection looking at part of the service
Beeston Lodge Nursing Home is a nursing home registered to provide personal and nursing care for up to 28 people, including people living with dementia. At the time of our inspection, on 11 December 2020, there were 26 people living at the service. Accommodation was provided over two floors and a lift was available. There were three communal living areas.
People’s experience of using this service and what we found
Systems and processes in place were not sufficient to protect people from abuse or neglect and incidents were not reported effectively.
Risks to people were not reviewed regularly or kept up to date or actioned when required. Care plans and record keeping was poor which put people at risk of harm.
Staffing levels were not adequate, and the service relied heavily on agency nurses to cover shifts on a daily basis. Concerns were identified around the competency of nursing staff and training records were unclear.
People’s nutritional needs were not managed effectively.
The environment was not clean, not effectively maintained and unsafe in areas. Measures for evacuation in the event of an emergency were insufficient and not up to date.
Infection control procedures were inadequate, staff were not wearing protective personal equipment (PPE) or following government guidance effectively. It was unclear if regular COVID-19 testing was performed.
Medicines were not managed safely, and it was not clear staff were trained or supervised in medicines management.
Lessons were not learned when things went wrong, this meant people were at risk of incidents reoccurring.
There was poor leadership and poor oversight of the service. Systems and processes to monitor the service were ineffective and this had impacted on the quality of care and treatment people had received.
We reported our concerns to the management team who sent us an action plan of improvements. However, following further concerns from the local authority and on our return ten days later, significant improvements had not been made, this left people at ongoing risk of harm.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 12 March 2020 and this is the first inspection, therefore this service is inspected but not rated.
Why we inspected
We received concerns in relation to people’s nursing care needs including; poor pressure area care, neglect of people, records not being up to date, a lack of staff, high use of agency nurses, poor use of PPE, lack of accurate weight recording, and a lack of referral to external health care professionals. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.
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 have identified breaches in relation to Regulation 12 (Safe Care and treatment), Regulation 13 (Safeguarding from abuse), Regulation 15 (Premises and equipment), Regulation 17 (Good Governance), Regulation 18 (Staffing) Registration Regulation 18 (Notification of other incidents) at this inspection. These are requirements for the Health and Social Care Act 2008 (Regulated Activities).
After the first inspection site visit, we sent the provider a letter of intent of possible urgent enforcement action and requiring an action plan for immediate improvement of the concerns identified.
We were not reassured by the response from the provider and on 15 December 2020 we issued a notice of decision to impose conditions on the registration. These conditions prevented the provider from admitting new service user’s without prior written agreement of the Commission and set specific compliance improvement required by 18 December 2020.
When we returned to the service on 21 December 2020, we identified that improvements set out in our notice of decision had not been made and people were still at risk of harm. We therefore wrote a notice of proposal to the provider proposing that we would take further enforcement action to remove the location of Beeston Lodge Nursing Home from the provider’s registration.
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.