Beaconville 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 requires improvement. At this assessment, the rating remains requires improvement. This meant some aspects of the service were not always safe, putting people at risk of avoidable harm. There were some unsafe areas within the environment that had not been identified and a lack of guidance to allow staff to support people living at the service with their care and support needs. The service was in continued breach of legal regulations in relation to safe care and treatment and we identified further breaches in relation to staffing and fit and proper persons (recruitment).

This service scored 56 (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 had recently adopted a culture based on openness and honesty. The service had a service improvement plan, identifying some of the concerns we found at this assessment. The provider had appointed a new manager who was open to our feedback, taking action to address the concerns identified and wanted to drive improvements at the service. The manager had started to embed a process of analysing falls, to identify any themes and trends and implement any learning to minimise the risk of further falls. The manager showed us a recent audit where themes had been identified, action had been taken, this was communicated to the team and falls had decreased for the person.

The service worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed and monitored. People had hospital passports, which contained up-to-date information on the person’s care that went with them in the event they needed emergency hospital treatment. The service had recently had an incident where a person could not be supported by the service to attend an appointment, due to specific equipment not being available. External professionals were contacted, and equipment was put in place to prevent this from happening again. Healthcare professionals praised the staff efforts to help a person attend a health appointment for future. A professional told us, “It was a frustrating situation due to the efforts we’d all gone to, to arrange it, but an easy detail to have overlooked and the care home responded promptly.”

The service worked with people and healthcare partners, such as the local safeguarding team, to understand what being safe meant to them and the best way to achieve it. The manager concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Records we saw had clear information in relation to restrictions and recorded authorisations, the services electronic care planning system alerted the manager when deprivation of liberty safeguards needed to be reviewed and re-submitted to the local authority. Staff told us they would raise any signs of abuse to the relevant people and had received safeguarding training, records confirmed this. Important people to those living at the service told us they felt their loved ones were safe. One relative told us, “I found (Person’s name) a place here at Beaconville and since then (Person’s name) has been well looked after and safe.”

The service did not always work well with people to understand and manage risks. Some records relating to people’s care lacked guidance to enable staff to support the person well. For example, we found some records relating to catheter care did not have adequate guidance around monitoring and cleaning of the catheter, which potentially put people at risk of infection.

We identified some air mattresses preventing skin damage had been incorrectly set, following the person’s most recent weight. We discussed this with the manager, who took immediate action in implementing a system to confirm the correct setting daily.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe care and treatment.

Relatives told us they had access to their loved one’s care notes, allowing them to be provided with up-to-date information and felt they were consistently involved in the person’s care.

The service did not always detect and control potential risks in the care environment. The service had building work taking place at the time of the assessment, this had not been risk assessed putting people at possible risk of harm. For example, some fire doors within the building did not automatically close in case of a fire, putting people at risk of a fire spreading. We discussed this with the manager at the time, who told us they would take action to introduce these risk assessments. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe care and treatment.

Relatives did not raise any concerns with the environment. One relative told us, “In the last 8-10 months, money has been spent on refurbishment. The hall carpets needed changing, and the home is in the process of doing this at the moment.”

The provider had not ensured all staff had appropriate support, supervision and appraisals. The provider had enough qualified, skilled and experienced staff to support people with their care needs. We discussed this with the manager who had identified these shortfalls and had a plan to address these concerns. The provider could not be assured people were protected from being cared for by unsuitable staff. The service had not obtained satisfactory evidence of potential employees’ conduct in previous employment. This put people living at the service at risk of harm. We discussed this with the manager, who took immediate action to resolve this. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to staffing and fit and proper persons (recruitment).

Relatives told us they felt there was enough staff available to support people, and we observed during our site visits this was the case. We received mixed feedback from staff around staffing levels, comments included “I do not feel there are enough staff” and “It is a big change because now we have a lot of people, more staff and more working as a team”. The manager told us whilst they did not have a formal dependency tool to calculate how many staff they needed to support people, they listened to staff and completed walkarounds at busy times to identify if extra staff were needed.

The service did not always assess and manage the risk of infection. People were placed at risk of harm from legionella-based contamination because checks were not being made, and processes were not followed for water temperature checking. We spoke to the manager about this, who had arranged for these checks to be completed. However, these checks had not yet been embedded in the services processes. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to good governance.

The manager completed monthly infection control audits, including environment, laundry, training, staff knowledge, and COVID outbreak management. Staff told us there was enough PPE (Personal Protective Equipment) and had received infection control training, records confirmed this. Relatives were positive about the tidiness and cleanliness of the service. Comments included, “(Person’s name) room is so nice, tidy and clean. There are always cleaners around”, “It’s clean and no nasty smells. (Person’s name) just had a brand-new bed.”

The service did not always ensure that medicines and treatment were safe, met people’s needs, capacities and preferences. We identified further work was needed in relation to protocols for ‘when required medicines’ (PRN). Where people were prescribed medicines to be administered as PRN, some guidance was not in place and needed more detail to provide guidance to staff. For example, around non-medicine methods such as techniques to deescalate behaviour that could challenge and distress the person, before specific medication might be needed to be administered. Most staff administering medicines had up-to-date training, and the clinical lead had assessed their competency within the last year. The manager was aware of those who had not yet completed their refresher training and had a plan to address this. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe care and treatment.

However, relatives did not raise any concerns in relation to medicine. One relative told us, “I’ve witnessed medicines rounds- perfect. They let me know if anything happens. We are in regular contact.” Medicines were stored securely. Medicines audits were effective in identifying medication errors, and appropriate action was taken when errors had occurred. The service had made improvements in relation to covert medicine, and a robust stock check process was now in place.