We carried out an unannounced focussed inspection of The Beeches Nursing and Residential Care Home on 1 October 2018.

The Beeches Nursing and Residential Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. At the time of the inspection there were 20 people who used the service.

At our last comprehensive inspection of The Beeches Nursing and Residential Care Home on 13 and 22 August 2018 we found evidence that people who used the service were at risk of significant harm. We found breaches in seven regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The inspection identified that people did not receive safe care and treatment. We found serious concerns with the management of medicines. Risks for people who used the service were not always adequately assessed to ensure people were safe. We found areas of the service to be unclean and infection control was poor. The passenger lift had not had a thorough examination as required under the Lifting Operations and Lifting Equipment Regulations (LOLER). The arrangements for fire safety were inadequate. At times there were insufficient staff to meet the needs of people who used the service and this had resulted in people’s care being compromised. Profiles were not available for all agency staff who worked at the service. This meant the provider could not be sure agency staff were suitably qualified and had the clinical skills to support people and to confirm they were of good character.

At the inspection on 13 and 22 August 2018 we also found that staff had not received supervision on a regular basis. The standards within the induction programme provided at the service were not aligned with the standards in the Care Certificate. The Care Certificate is an agreed set of standards that sets out the knowledge, skills and behaviours expected of specific job roles in social care. There were no records to confirm agency staff had received an induction in relation to people who used the service, expectations and safe working practices. We found that the provider was in breach of regulation in relation to consent because the Mental Capacity Act (2005) guidelines were not always followed. Many bedrooms and communal areas in need of redecoration and refurbishment. There was insufficient monitoring and oversight of people’s nutrition and hydration. People were not always treated with dignity and respect. Staff failed to ensure people’s needs were met and this compromised their dignity. Care records were insufficiently detailed to ensure the care and treatment needs of people were met. Activities and outings were limited and particularly for those people living with a dementia. Quality monitoring of the service was ineffective as it had not identified the concerns that we had found at the inspection. We rated the service as inadequate.

Due to our concerns we served a Notice of Decision to restrict admissions to the service without prior agreement of the Care Quality Commission.

We carried out this focussed inspection of the service on 1 October 2018 to determine if any improvements had been made in relation to safe care and treatment. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Beeches Nursing and Residential Care Home on our website at www.cqc.org.uk. The inspection highlighted some improvement. However, we did identify a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the time of the inspection the registered

We carried out an unannounced inspection of The Beeches Nursing and Residential Care Home on 13 and 22 August 2018. The first day of the inspection was unannounced. We informed the manager of our second day of inspection .

At our last comprehensive inspection of The Beeches Nursing and Residential Care Home on 8, 15 and 22 November 2017 we found evidence that people who used the service were at risk of significant harm. We found breaches in five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The inspection in November 2017 identified that people did not receive safe care and treatment. Staffing levels and the deployment of staff did not ensure people's care needs were met. Recruitment procedures were not robust. Risks to people were not appropriately assessed and managed. We found serious concerns with the management of medicines. The premises and equipment were not clean and properly maintained. Infection control was poor and people had not been protected from environmental risks. Emergency evacuation plans were not available for all people. The certificate to confirm that there had been professional testing of the electrical systems, circuits and any other service carrying electricity around the building was not available. The building was not suitably heated and environmental risks were not managed. We rated the service as inadequate.

We carried out a focussed inspection of the service on 20 March 2018 to determine if any improvements had been made. The inspection highlighted some improvement. However, Inspectors did identify breaches in Regulation 11: Need for Consent and Regulation 12: Safe Care we identified two breaches in regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found further work was needed to ensure mental capacity assessments were decision specific and we found that best interest decisions were not recorded in care plans. Improvements were needed in bathrooms and in the cleanliness of the service. We rated the service as Requires Improvement.

Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all five key questions to at least Good.

At this inspection of the service on 13 and 22 August 2018 we found the service had deteriorated and rated the service as Inadequate. We found the provider had failed to follow their action plan. We identified significant shortfalls in the quality of the care people were receiving and we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Due to our concerns we served a Notice of Decision to restrict admissions to the service without prior agreement of the Care Quality Commission.

The Beeches Nursing and Residential Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. At the time of the inspection there were 20 people who used the service.

At the time of the inspection the registered manager was absent from the home. However, the deputy manager had stepped up and was acting as manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our inspections in November 2017 and March 2018 we found that the home was in breach in relation to safe care and treatment. At this inspection we looked to see if the required improvements had been made. W

We carried out an unannounced comprehensive inspection of this service on 8, 15 and 22 November 2017. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk”

The Beeches Nursing and Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. At the time of the inspection there were 17 people who used the service.

At the inspection of the service in November 2017 we rated the service as Inadequate. People did not receive safe care and treatment. Staffing levels and the deployment of staff did not ensure people's care needs were met. Recruitment procedures were not robust. Risks to people were not appropriately assessed and managed. We found serious concerns with the management of medicines. The provider was not ensuring the premises and equipment were clean and properly maintained. Infection control was poor. The provider had not protected people from environmental risks.

Emergency evacuation plans were not available for all people. The certificate to confirm that there had been professional testing of the electrical systems, circuits and any other service carrying electricity around the building was not available. The building was not suitably heated and environmental risks were not managed.

Staff were not up to date with their training and induction records were incomplete. There were insufficient nurses with the right clinical skills to care for people. Appropriate checks had not been made to confirm all bank and agency nurses were suitably trained with the right clinical skills. Nurses employed at the service had not received clinical supervision and the registered manager had not received supervision and an annual appraisal.

Care plans were insufficiently detailed to ensure the care and treatment needs of people who used the service were met. Care plans were not reviewed and updated on a regular basis. Mental capacity assessments and best interests were not available within care plans. Systems and processes for monitoring the quality of the service provision were poor.

Since our last inspection of the service the Care Quality Commission has continued to monitor the service. We also shared our concerns with commissioners. In light of the serious concerns, executive strategy meetings were set up and chaired by a senior manager of Durham County Council and CQC attended some of these meetings. These meetings have been on-going as a result of the serious concerns we identified. Throughout this time, representatives from Durham County Council and the Clinical Commissioning Group have visited the service to provide support and advice to the registered manager and staff.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection on 20 March 2018 we found improvements had been made and rated the service as Requires Improvement.

Although improvements had been made

The Beeches Nursing and Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides nursing and personal care for up to 31 people some of whom are living with a dementia. Care is provided over two floors. On the first day of the inspection there were 23 people who used the service, reducing to 18 people on day three of the inspection.

This inspection took place on 8, 15 and 22 November 2017. The inspection was unannounced (all of the inspection days), which meant that the staff and provider did not know we would be visiting.

At our last comprehensive inspection in September 2015 we rated the service as Good. However, we found a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at that time, as the provider was not always maintaining an accurate, complete and contemporaneous record in respect of each person who used the service as some care records had not been updated or evaluated for several months. We revisited the service in June 2016 to check if improvements had been made and found that action had been taken to address the breach.

At this inspection of the service in November 2017 we rated the service as Inadequate.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People did not receive safe care and treatment. Staffing levels and the deployment of staff did not ensure people's care needs were met. Staffing levels were not effectively monitored. We spoke with the provider after the first day of the inspection who agreed to increase staffing levels. Recruitment procedures were not robust to ensure those staff working with people who used the service were suitable to do so.

Risks to people were not appropriately assessed and managed. The provider was not ensuring that people who had behaviour that challenged were appropriately supported, and that incidents were analysed, which exposed them as individuals, and other people, to the risk of harm.

We looked at the arrangements in place for the management, storage, recording and administration of medicines and found serious concerns with the management of medicines. There were unexplained gaps in people’s medicine administration records (MAR) which records when people are given their medicines. There were no records for those medicines prescribed to be applied to the body in a patch (for example for pain relief) to confirm where and when the patch had been applied to different areas of the back, upper arm or chest. Medicines prescribed as a patch should be rotated to avoid applying to the same area for 14 days. Some people had not received their medicines as these had been out of stock. People had not always received their medicines at the time they were prescribed.

The provider was not ensuring the premises and equipment were clean and properly maintained. Infection control was poor. We found toilets stained with faeces and furniture, walls, sinks, carpets and floors which were dirty and stained. The service had a malodour and many of the carpets were worn and dirty. We pointed this out to the registered manager and provider at the time of the inspection and they took some action to address our concerns, however further work was needed.

The provider did not protect people from environmental risks. Throughout the inspection we found concerns with premises safety. We found the medicine room unlocked. There were unlocked doors leading to a boiler room and

This focused inspection took place on 8 June 2016 and was unannounced. This meant the staff and provider did not know we would be visiting.

The Beeches Nursing and Residential Care Home provides care and accommodation for up to 31 people who require nursing or personal care. On the day of our inspection there were 16 people using the service.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last unannounced, comprehensive inspection on 23 and 24 September 2015, we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Beeches Nursing and Residential Care Home on our website at www.cqc.org.uk.

This focused inspection took place to follow up the breach relating to the service was not always maintaining an accurate, complete and contemporaneous record in respect of each service user.

After the comprehensive inspection on 23 and 24 September 2015, we asked the provider to take action to make improvements. The provider wrote to us to say what they would do to meet legal requirements in relation to this breach. We undertook this focused inspection to check that the registered provider had followed their action plan and had made improvements at the service.

We found improvements had been made in the way the home maintained an accurate, complete and contemporaneous record in respect of each service user.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives and the staff supporting them, and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

During our visit to The Beeches, we checked the premises and found it provided a safe, suitable and clean environment.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We discussed DoLS with the manager, who told us that she was aware of the impact of the recent supreme court decision about how to judge whether a person might be deprived of their liberty and had been in contact with the local authority to request clarification before submitting applications.

We saw copies of mental capacity assessments in people’s care records and where people had been found to lack the capacity to make a decision, best interest decisions had been made.

Before anyone received care from the service, pre-admission information was obtained and assessments of people’s individual needs took place. This meant the staff knew how to care for the people who used the service.

The manager set the staff rotas and took people’s care needs into account when making decisions about the number of staff required. We saw that there were sufficient numbers of staff on duty in order to meet the needs of people using the service.

Is the service effective?

Each person had individual support plans which set out their specific care needs and people and their family members had been involved in the assessment and planning of their care.

We found that there were clear processes for obtaining people's consent and ensuring people could make informed decisions where appropriate.

Staff we spoke with were knowledgeable about the people who used the service and could describe to us their individual needs and likes.

Is the service caring?

People's needs were assessed and care and treatment was planned and delivered in line with their individual support plan.

We observed staff supporting people in a caring and sensitive way.

People told us they were happy with their care. They told us, “I like it here”, “it’s a happy place”, “I like it that people mix” and “it’s the best place I’ve been in.”

Is the service responsive?

People were asked for their views on a regular basis. A family member told us “I’ve always been able to approach the manager. They’ve always said come and see me any time.”

Records showed that people’s needs had been taken into account and care and support had been provided in accordance with people’s wishes.

Family members we spoke with said they were satisfied with their relative’s care and were aware of how to make a complaint. They did not raise any complaints or concerns with us about their relative’s care.

Is the service well-led?

The home had a manager who was not registered with CQC. The manager told us she was in the process of submitting her application.

We saw that a quality assurance plan was in place, which included a list of audits to be carried out each month however the last recorded audit was in April 2014. No audits had been carried out during the manager’s recent maternity leave.

The manager told us that the provider made regular visits to the home however none of these visits were recorded. This meant the provider was unable to provide evidence that regular audits were undertaken to gather information about the safety and quality of their service.

When we inspected the service people told us they were satisfied with the care and support that they were receiving. “The staff are champion” and “This is a great place to live” were some of the positive comments people made to us during the inspection. We saw that staff and people who used the service were comfortable in each other’s presence and people told us they trusted the staff and felt safe living at the home.

We saw that staff were supported by the management team at the home to do their jobs properly.

Audits had been carried out in areas such as care documentation, accidents that had occurred in the home and the dependency levels of the client group. We saw that effective systems were in place to assess and monitor the quality of service that people received.

We saw that complaints are dealt with according to the home's policy and procedures and when people had raised concerns they were dealt with promptly by the manager.

We observed how staff supported people. We saw that staff understood the needs of the people in their care and were able to communicate with them, understanding their physical as well as psychological needs.

One person said “they always ask you what you would like to do.”

One relative told us that “I can visit anytime; I am always made very welcome. The staff look after him very well”

We spoke with two people who used the service. Both of them told us that they felt safe living at The Beeches. They explained that they knew who to talk to if they had any concerns and they thought that staff treated them well.

One relative that spoke to us told us that they had no concerns about their relative’s safety. They explained that the home always kept them informed if there were any concerns around their relative’s health.

This inspection took place on 23 and 24 September 2015 and was unannounced. This meant the staff and provider did not know we would be visiting.

The Beeches Nursing and Residential Care Home provides care and accommodation for up to 31 older people and people with a dementia type illness. On the day of our inspection there were 13 people using the service. The home also provided day care facilities for elderly people from the local community.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The Beeches Nursing and Residential Care Home was last inspected by CQC on 25 September 2014 and was non-compliant in one area; the provider was unable to provide evidence that regular audits were undertaken to gather information about the safety and quality of their service.

There were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.

Thorough investigations had been carried out in response to safeguarding incidents or allegations and accidents were recorded and analysed.

Staff training was up to date and staff received regular supervisions. Some appraisals were out of date but these were planned.

The home was clean and suitable for the people who used the service.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. We discussed DoLS with the registered manager and looked at records. We found the provider was following the requirements in the DoLS.

All of the care records we looked at contained evidence of consent.

People who used the service, and family members, were complimentary about the standard of care at The Beeches Nursing and Residential Care Home.

Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

We saw that the home had a full programme of activities in place for people who used the service.

Care records showed that people’s needs were assessed before they moved into The Beeches Nursing and Residential Care Home and care plans were written in a person centred way. However, care records, risk assessments and charts were not always accurate or up to date.

The provider had a complaints policy and procedure in place and complaints were fully investigated.

The provider had a robust quality assurance system in place and gathered information about the quality of their service from a variety of sources.

You can see what action we told the provider to take at the back of the full version of the report.