Last updated: 9 February 2026
"Supportive staff culture and engaging activities programmes, but unsafe medicines practices and ineffective governance audits hold it back."
Medicines optimisation Score:1 The service did not make sure that all medicines and treatments were safe... PRN protocols were in place. However, they did not give the staff clear guidance... led to staff administering medicines unsafely... The service had not followed the principals of the Mental Capacity Act 2005 (MCA) in regard to giving medicines covertly.
All staff we spoke with said that Beckfield House was a supportive and caring place to work. Staff told us that the registered manager and the management team encouraged them to report any issues or ask for support should they need any.
Safe and effective staffing Score:3 People and their relatives told us there was always enough staff including in the evenings and weekends... The service tried to cover sickness with their own staff including bank staff. Where needed they used agency staff.
despite staff being trained on how to keep people safe from abuse and neglect, during the inspection process the registered manager identified an occasion where staff had not identified a potential safeguarding situation.
Governance, management and sustainability Score:1 Although the service had clear responsibilities and roles, their systems and auditing processes were not effective in ensuring accountability or good governance.
The service had a team of activities staff who worked to ensure people were supported to be both physically and mentally active... trips into the village and the local pub. The activities staff had organised with a local library for there to be a library on site.
Staff made mistakes giving medicines because instructions were unclear on painkillers and crushing tablets, and they missed a possible abuse risk.
PRN protocols... did not give the staff clear guidance on what signs and symptoms... The service did not have a protocol for staff to follow when administering these medicines which had led to staff administering medicines unsafely... staff had not identified a potential safeguarding situation.
Managers' quality checks did not spot ongoing problems with medicines and missing details in care records.
the service had several audits relating to the management of medicines. However, there were a limited number of peoples medicines records audited ever month which meant they had not identified all issues... Care plan reviews and audits had not identified where information was missing.
Staffing is adequate but nothing special, they use agency workers sometimes when people are sick.
The service tried to cover sickness with their own staff including bank staff. Where needed they used agency staff, requesting staff that had worked at the service before.
AI Generated
Last inspected: December 2024
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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