Beaconsfield Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to managing risk, infection prevention and control, managing medicines safely, recruitment and premises being clean.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although leaders were able to describe the processes in place, they had not identified where these processes were not always effective or sufficiently robust to ensure learning from complaints would always take place. This meant there were missed opportunities to identify learning and embed good practice. There was a system in place to investigate and respond to complaints and concerns however, there was a lack of evidence to demonstrate complaints had been responded to and the outcome shared with the staff team. The manager was responsive and told us they would review complaints and introduce a better system to ensure the complaints folder contained all of the relevant information.

People and their relatives told us they felt the service listened to them and responded to any concerns they had. Staff told us they were able to raise suggestions and highlight areas for improvement.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The manager confidently described the processes in place for when people transitioned into and out of the service and described what was in place to ensure smooth transition between the service and hospital when required. A professional involved with the service told us about a person who moved into the service, they said, “I felt the assessment was thorough, took into account the risks associated with the service user and developed support around this.”

People were consistently supported when they were distressed and there was a focus on planning for a good day and understanding what had caused people distress so positive changes could happen.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns with the local authority safeguarding team as required.

Staff told us they usually received feedback following incidents. We could not be assured that lessons learned from managers reviewing incidents were always shared with the whole team and understood in order to support learning and improvement. The manager told us they were working on improving this.

People, staff and visitors were at risk harm from passive smoking.

Most people told us they felt safe living in the service and relatives agreed. One relative told us, “I do feel he’s safe, he’s very happy and the staff seem very good.” There was no restrictive practice being used in the service.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, people had smoking risk assessments which stated they smoked in their bedrooms or flat. One person’s smoking risk assessment asked the likelihood of secret smoking if restrictions were imposed, the response had been marked as unlikely. The provider told us they try to prevent smoking in the home, but people don’t listen to them, therefore the likelihood of secret smoking should have been recorded as almost certain. The impact of secret smoking was recorded as insignificant which did not consider the serious risks of fire to this person and other people living in the service. The provider told us they try to encourage people to go outside, but people don’t listen to them. The provider provided ashtrays in bedrooms but did not provide other safety items to mitigate the risk such as fire-retardant aprons. Risk assessments were not always robust and did not always contain sufficient information to guide staff how to support people safely. For example, 1 person suffered from a medical condition which affected their breathing, they had a risk assessment in place which told staff to report symptoms, however, it did not detail what the symptoms associated with this condition were. Some people were on fluid monitoring however there was no detail in their risk assessments to inform staff how much fluid they should have. Several risk assessments were completed using scoring to assess the risk, however, not all questions had been responded to accurately which meant the score and assessed level of risk may not always be accurate. Care plans and risk assessments did not evidence that people with a learning disability or mental health conditions were supported and empowered to take risks.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

During the inspection we had concerns about the environment, for example, gaps in fire doors. We made a referral to the Fire Service who conducted an inspection. They found 2-bedroom doors, belonging to people who smoked, were not approved fire doors. Several people smoked in their bedrooms and on 1 occasion we saw a person smoking in the dining room. This was in direct contradiction with the providers smoking policy which stated. “Smoking is not allowed inside any part of the buildings, including bedrooms, lounges, or communal areas.” People, staff and visitors were at risk of harm in the event of a fire.

The service had an external fire escape, a person smoked on the external fire escape. There was a piece of discarded equipment underneath the external fire escape as well as green matting and plastic flowerpots. This meant there was a potential fire risk if cigarettes were not discarded appropriately.

The kitchen had 3 cupboard doors missing. On the first site visit one of the cupboards with no door contained a bottle of thick bleach and a bottle of multi-surface cleaner. On the second site visit we observed unlocked cupboards in the kitchen containing oven cleaner, antibacterial multi- surface cleaner, and cleaning spray with bleach. In addition, we found a bottle of cleaning spray with bleach and a bottle of multi-surface cleaner on the kitchen work surfaces. People had access to the kitchen, there was a risk these products could be misappropriated and or swallowed.

We found 1 person’s bedroom did not have a window restrictor in place.

There were no activity staff available, no activity schedule and we did not observe any activities taking place within the service during our 3 on-site visits. People told us staff were busy, 1 person told us they were happy just watching television but then told us, “It’s boring in the house” and 2 other people told us there were no activities in the house. There were sufficient staff to meet people’s care needs. And people told us staff supported them with their personal care, drinks and meals. A relative told us, “There is not a lot for him to do there, he goes to the shops quite often. There are no activities that I know of, just the lounge and watching telly.” We saw this was something the manager was trying to address in a team meeting which took place in September 2024.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider’s recruitment and selection policy was not robust in identifying the full requirements of Schedule 3 of the Health and Social Care Act 2008. It also did not robustly cover starting new staff members without a DBS.

We checked recruitment records and found full employment histories were not available for some staff. This meant the provider was unable to confirm whether further references should have been sought from previous employers that might have impacted on the staff member's suitability. We found the provider had not sought satisfactory evidence of conduct or the reason or leaving previous employment related to health or social care, children or vulnerable adults. This meant the provider was not following the principles of Schedule 3 of the Health and Social Care Act 2008. We discussed this with the nominated individual who told us they would amend their recruitment processes to help ensure full employment histories were obtained from staff consistently in the future and provisions would be made for the provider to seek the reason for staff leaving all previous health and social care roles.

Eleven staff had not attended a fire evacuation drill in the last year. This was important because of the fire risks within the service.

The providers policy did not specify the frequency of staff supervisions, there was a supervision contract in staff recruitment files which stated supervisions should take place every 6-8 weeks. Staff had not received regular supervision in line with their supervision contracts.

The manager had a training matrix in place which evidenced all staff had completed all of their statutory and mandatory training.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed 1 person’s bedroom with rubbish on the floor and cigarette ash all over a table which had an open packet of biscuits sitting amongst the ash. We observed cigarette burns and ash on flooring. We also observed windowsills with cigarette burns in the service and in 1 person’s bedroom we observed a full ashtray.

The kitchen was unclean. The cupboards without doors were covered in grime, the deep fat fryer and the microwave were visibly dirty.

We found some bins which did not contain bin liners and found the laundry bin, which contained discarded personal protective equipment (PPE), did not have a lid. The provider was responsive to these concerns and placed bin liners in bins and purchased a new bin with a lid for the laundry.

There was a strong malodour in the lounge. There was a fan in the lounge which was dirty and very dusty, and an extension lead which was visibly very dirty.

The dry store food cupboard contained several foods which were left open and did not have opening dates recorded on them. We found cooked chicken and a bowl of baked beans unlabelled in the fridge. There were 3 packets of biscuits left open in the kitchen cupboard with no opening date recorded on them.

The service cleaning schedules which were in place did not evidence who had completed the cleaning and what had been cleaned, for example, bathroom 1 was ticked but contained no further information. People and their relatives told us they thought the home was clean.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning.

There were no PRN protocols for Lorazepam and Paracetamol for 2 people whose medicines files we checked. The deputy manager started writing these while we were on site. When these were completed, they did not contain the level of detail required to ensure people were not being unnecessarily medicated. They also did not correctly state how long following administration, the medicines would take to be effective.



We observed staff were systematically offering ‘as required’ medicines to people and recording refused when they were not wanted. There were several gaps in MAR charts with no explanation as to why the medicines had not been administered or signed for.

We found there was confusion over some medicines being regular or ‘as required’. The MAR chart identified 2 medicines as regular. Staff were offering both as if they were ‘as required’ medicines. During our first site visit a staff member was advised, by a visiting professional, that any regular medicines which had been refused for 5 days, should be discussed with the GP. We asked if this had been completed on our second site visit 48 hours later. The GP had not been contacted. The providers systems and processes in place failed to identify MAR charts did not always match the prescription.

The provider was having ongoing support around the safe management of medicines from the local authority, however, further learning and application of safe practices was required. People did have assessments to identify if they were able to safely manage their own medicines and the manager was working to the principles of Stopping over medication of people with a learning disability and autistic people (STOMP).