Beech House Nursing 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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Safety concerns had been identified in a fire risk assessment and whist some action had been taken to address these concerns, the provider had not addressed all actions in a timely manner which placed people at continued risk of harm in the event of a fire. We discussed this with the registered manager who was proactive in putting steps in place to address this immediately.

A safeguarding concern had been investigated and it had been identified that appropriate mental capacity assessments and best interests’ meetings had not been completed. Despite these findings, we found mental capacity assessments and best interests’ meetings had still not been completed when required following the event.

Whilst staff were well trained and knowledgeable, we observed 2 incidents where staff had not followed their moving and handling and medicines administration training which may have placed people at risk of harm.

Despite these incidents, staff we spoke with were knowledgeable about how to maintain people’s safety and were passionate to learn and provide care in the way people wanted to receive it. The registered manager was open and accountable and was positive about learning from where things had previously gone wrong to embed good practice moving forward.

The provider 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.

People were supported to access health and social care professionals when needed and staff knew when to escalate concerns regarding people’s health. We saw evidence of referrals to professionals including GP’s, speech and language therapists (SALT) and occupational therapists. Advice from healthcare professionals was followed to enable people to receive the care they needed.

When people were admitted to the home, pre assessments were undertaken and information regarding people’s care needs were shared with staff to enable them to meet people’s needs safely immediately following admission.

The provider did not always have systems in place that enabled them to concentrate on protecting people’s right to live in safety and free from abuse, avoidable harm and neglect and uphold their rights under the Mental Capacity Act 2005. The provider did not always share concerns quickly and appropriately.

Where safeguarding concerns had been shared with the home from the local authority and CQC, statutory notifications had not always been submitted to notify CQC of allegations of abuse. The registered manager acknowledged this was due to a misunderstanding that these did not need submitting as the local authority and CQC were already aware but immediately submitted them retrospectively during the course of the assessment.

Mental capacity assessments had not always been completed and best interests’ meetings had not always been undertaken when needed, such as where people with a cognitive impairment used bed rails. The registered manager took steps to address this once we raised it. Deprivation of Liberty Safeguards had been applied for when needed.

However, people told us they felt safe and relatives felt that people were supported by staff who kept them safe. One person told us, “I’m very safe, it’s so good here, just nice.”

A safeguarding policy was in place and people were supported by staff who had completed safeguarding training. Staff understood how to raise safeguarding concerns and were comfortable in doing so if they needed to.

The provider did not always work well with people to understand and manage risks. Systems in place did not always enable staff to provide care to meet people’s needs that was safe and consistent.

Risk assessments were not always sufficiently robust to ensure staff knew how to manage clinical risks. For example, diabetic risk assessments did not include blood sugar ranges to guide staff when to escalate concerns. Whilst people had not been harmed, this meant the provider could not be assured concerns would be escalated.

Care plans and risk assessments were not always consistent and up to date. For example, 1 person’s eating and drinking care plan was inconsistent which may have placed them at risk of receiving the wrong diet. However, staff knew people’s risks well and people had not been harmed by this. Where we identified inconsistencies in care plans, the registered manager took immediate action to review and update them.

Clinical risks were not always monitored adequately which meant the provider could not be assured risks would be escalated when needed. Where people required weekly weight monitoring, this was not always undertaken at the required frequency which meant concerns may not be picked up. Despite risk monitoring not being robust, we found no examples of where this had impacted people’s safety and monitoring systems were immediately implemented.

People felt safe being supported with mobility and staff were knowledgeable about how to meet their needs. Despite this positive feedback, we observed 1 person being hoisted with insufficient staff which placed them at risk of harm. This was immediately investigated and addressed by the registered manager.

Despite concerns around risk management, people felt safe and provided positive feedback regarding how staff supported them to manage risk. Where concerns around risk management were identified, the registered manager took immediate action to put steps in place to reduce the risk of reoccurrence.

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

The provider had failed to address some identified actions in the fire risk assessment which placed people at risk in the event of a fire. We discussed this with them and the provider immediately took action to begin to address the concerns identified.

Window restrictors were in place, but they were not always compliant with current guidance which meant they could be tampered with and people could be potentially placed at risk of harm. We discussed this with the provider and action was taken immediately to commence replacement of the window restrictors and comply with guidance.

We observed keys being left in the inside of doors to both outside areas and to steep stairs which may have placed people at risk of harm. The provider immediately removed the keys when we raised this to maintain people’s safety.

However, electrical and gas safety tests had been completed and mobility equipment had been serviced within appropriate timescales to maintain a safe environment for people living at the home. Regular fire safety drills were undertaken and people were made aware of weekly fire alarm checks with signage evident throughout the home.

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

Staffing levels at night were insufficient to ensure there were enough staff to support people to leave the building in the event of an emergency. This was raised with the provider and they immediately increased staffing levels at night to maintain people’s safety.

Staff told us there were insufficient care staff at the home, although they did not feel this impacted on them meeting people’s care needs safely. However, people confirmed they felt staffing levels were sufficient and told us staff did not take long to respond to them when they needed them. One person told us, “I feel safe here, the staff are so wonderful, caring, friendly and kind. I press my buzzer and staff come to look after me.”

Staff were recruited safely and were required to complete pre-employment checks and inductions prior to commencing work to ensure they were able to meet people’s needs safely. The suitability of agency staff was considered prior to completing a shift and checks were made to ensure they had completed required training.

Staff told us they had supervisions and appraisals which they found useful. Staff were required to complete the Care Certificate and had mostly completed appropriate training to ensure they had the skills and competency to meet people’s needs safely.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Relatives gave mixed feedback regarding the cleanliness of the home which may have increased the risk of spread of infection. We observed cleaning being completed during our site visits but it was evident that not all parts of the home had been cleaned at the frequency required. For example, we observed some dusty areas and skirting boards were not always clean.

Cleaning schedules and detailed plans were in place to guide staff how to clean each area of the home and how to measure if this had been done effectively. However, we found some gaps in cleaning records which indicated cleaning had not been completed. Care staff confirmed they found it challenging to complete cleaning tasks effectively as well as fulfilling their caring responsibilities. The registered manager acknowledged these concerns and told us recruitment for another domestic member of staff was underway to address this and ensure cleaning was completed as required.

Staff wore Personal Protective Equipment (PPE) in accordance with current guidance to reduce the risk of spread of infection.

The provider did not always make sure that medicines and treatments were administered and recorded safely to meet people’s needs.

We found 1 instance where a person had kept a medicine in their room to take later in the day. Staff had recorded this medicine as being administered on the person’s medicine administration record (MAR). However, staff could not be assured the person had taken the medicine as prescribed which placed the person at risk of not receiving their medicines safely. The registered manager immediately investigated this and met with all staff to remind them of safe medicine administration protocols.

MARs had some gaps in recording indicating medicines had not been administered. No reason had been recorded for this. We raised this with the registered manager who investigated and fed back the legitimate reason for this. However, the missed medicines had not been picked up which placed people at risk of not receiving medicines as prescribed.

Protocols were not always in place to guide staff when to administer ‘when required’ medicines. A staff member told us protocols had not been implemented where people had not yet required a particular ‘when required’ medicine. These were immediately implemented when we raised our concerns. Where protocols were in place, they provided clear guidance for staff when to administer these medicines. People told us they were given ‘when required’ medicines when they needed it. One person told us, “If I’m in pain, I just say, ‘can I have a painkiller?’ and staff get it for me.”

Medicines were stored safely in a locked cabinet in a locked room. Fridge and room temperatures were undertaken daily to ensure medicines were stored at a safe temperature. Controlled drugs were stored and administered safely.