BH 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. This is the first assessment for this service. This key question has been rated 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. The provider was in breach of legal regulation in relation to medicines management, staff training and supervision and record keeping. The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The provider did not always make sure medicines were managed safely, people received their medicines as prescribed and records were kept accurately and consistently. Although safeguarding, accident and incidents were documented, lessons were not always learnt to continually identify and embed good practice. People felt safe living at the home and in receipt of care. Systems and processes were in place to support people to transition safely and effectively into the home. Checks of the environment and equipment were completed in line with guidance to ensure people were kept safe. The home was clean with effective infection control practices in place.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Accidents and incidents were recorded on the provider’s electronic care planning system. We looked at a selection of records and noted these just explained what had happened and the staff’s response. At the time of assessment, there was no separate file or system in place for documenting these, and as such, no log was in place which detailed actions, taken, outcomes and could be used to monitor patterns and trends. For example, we noted one person had experienced 4 falls over a 2 week period in October 2024. There was no record to indicate these falls had been reviewed together, potential trends identified, and action taken to reduce the likelihood of a reoccurrence. A falls, accident & incident audit had been completed in September 2024. However, this merely covered whether a process was in place was recording incidents, if staff knew what to do, if training was provided and if any learning was evidenced. This last point was answered by stating accidents and incidents were discussed in handovers and staff meetings. The audit did not cover all accidents and incidents over a set time period, what happened, actions taken, lessons learned and whether any changes made to practice had been made and if these had been effective. As a result, it was not clear what, if any learning had been identified.

The provider worked closely with commissioning teams and social workers when new referrals were received. This helped ensure the transition process, whether from a person’s home or from another care provider, into BH Residential Care Home was successful. The home was currently using a high number of agency staff to cover shortfalls in staffing numbers. However, to ensure continuity of care, the same agencies and agency staff were used on a consistent basis.

Overall, people told us they felt safe living at the home. Relatives also reported no concerns with the safety of the care provided. Information regarding the safeguarding process and how to raise concerns was displayed within the home. Staff told us they had completed training in safeguarding and knew how to report any concerns. The home had a file in which any safeguarding referrals were stored. At the start of our assessment, there was no log in the file, to document each referral, the alleged abuse, actions taken and outcomes. We fed this back to the manager and one was subsequently added. However, we noted this was more of an audit document than a log. Whilst this contained some information on what had occurred and actions taken, further information was needed around the identifying of patterns and trends, lessons learned and any changes to practice as a result.

People’s care records contained a range of generic and individual risk assessments, which explained risks to people and how these should be addressed. Key risks for each person were listed on the summary page, to ensure they were easily accessible to staff. However, we noted some assessments had not been completed fully and/or consistently, and where risks had been identified these did not always feed into people’s care plans. For example, the Cornell Depression Scale identified a person as being at risk of major depression, yet this was not referenced anywhere else within their care plan. Another person‘s choking risk assessment indicated no issues or concerns, yet this person had been assessed as requiring a pureed diet, which indicated issues with swallowing food and by extension a risk of choking.

Risk assessments of the environment and equipment used within the home had been completed, to ensure these were fit for purpose and used correctly. Ongoing safety checks had also been completed in line with legislation, with certification in place to confirm compliance. This included checks of gas and electrical safety and equipment such as the passenger lift and hoists. An up to date fire risk assessment was in place and each person had a personal evacuation plan, in case of emergencies.

Mixed feedback was provided by people and relatives regarding staffing levels. People told us they often had to wait for assistance and a relative stated, “I do think they are short staffed, but the staff they have are nice and look after [relative]. There is rarely any staff in the lounge area and sometimes we have had to go and find one, when one of the residents needs help.” The provider used a system, often referred to as a dependency tool, for determining staffing levels. However, this system did not clearly link people’s daily needs to how many staff were required to meet these, nor did it consider whether the reduction to 2 staff at night was enough to provide safe care. We were unable to evidence staff supervision was being completed in line with the provider’s policy. Records showed only 1 confirmed meeting had taken place, when these should have happened every 16 weeks. We also identified issues with training completion and the recording of this. The training matrix contained 53 courses, although it was not specified whether staff needed to complete all of these during their induction. One staff member was listed as having completed all of the 53 courses in March 2024. However, they only commenced employment in July 2024. Another staff was recorded as having completed some face to face training sessions in April 2024, when these sessions were not held until June and July 2024. Only 3 courses were listed as being face to face i.e. practical and did not include manual handling. As such, it was unclear how staff were taught to safely use equipment such as a hoist or slide sheet. We found the recruitment process had been carried out safely, with all required checks and references sought and verified.

Overall, the home was clean with effective cleaning and infection control processes in place. Handwashing guidance was displayed in toilets and PPE was accessible at specific points across the home. We identified some minor issues with malodours and the cleanliness of some toilets on the morning of our first site visit. The manager explained the housekeeping staff worked afternoons, rather than mornings with care staff responsible for any cleaning tasks up until them. As staff were busy getting people up and ready for the day, these areas had been missed. Staff confirmed they had received the necessary training, guidance and support to keep people and themselves safe and follow infection control procedures.

One person missed doses of their prescribed medicines as there was no stock available, this placed them at risk of harm. Another person did not have their weekly pain patch applied on the intended date, which meant they might have experienced unnecessary pain. People were not always given their medicines at the prescribed times, as the previous dose had been given too late in the morning. This resulted in there not being a suitable time interval before the next dose was due. Medicines that needed to be given at specific times, for example before or after food, were not always given at the right times, this meant the prescribed medicines might not work properly. When medicines needed to be given with a specific time interval between doses, the actual time the medicine was given was not always recorded, therefore the records did not show the medicines were given safely. When people had their medicines given covertly e.g. hidden in food or drink, there was not always information available to support staff to safely administer the medicines. In addition, we found there was not always the required authorisation in place. People’s allergy information was not always recorded on all of their medicine related documents, so there was a risk they might be given a medicine they had previously reacted to. When people had medicines or topical preparations, for example creams, to be given or applied ‘when required’, there was not always information available to support staff in knowing when to administer the medicine or the cream. There was a risk people might not get their medicine or cream when they needed them. The service had completed audits to improve medicines optimisation, however, they had not identified all of the issues found during this assessment. Therefore, we were not assured the audit processes were identifying and driving forward the improvements needed. The service was working with healthcare professionals to improve the management of medicines at the home.