Benson House 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 remained Good. 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 service was in breach of legal regulation in relation to people’s safe care and treatment in the way people’s medicines were managed at the service.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and staff were encouraged and supported to raise concerns, they felt confident they would be treated with compassion and understanding.

Staff told us they were updated about incidents and changes. Incidents and accidents were discussed in handovers, meetings and supervisions.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The home worked with a number of professionals to ensure continuity of care within the home. The home had regular visits from the GP and made appropriate referrals to healthcare professionals. People’s care plans contained a ‘hospital pack’, containing important information about the person. This meant if the person was admitted to hospital, this pack would accompany them ensuring the hospital was in possession of all relevant information.

Staff knew people and their risks well and told us how they worked with professionals to keep people safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately with the safeguarding team

People using the service and their relatives told us they felt safe and were happy with their care. We were told, “I feel safe, and I can bring concerns to the manager of the home” and “I really enjoy spending time with staff; they are really caring and look after me.”

Staff we spoke with knew people and their needs well, had access to safeguarding policies and received safeguarding training. Staff told us they would report any safeguarding concerns immediately. One said, “I can take concerns of abuse to my nurse and manager, and I can call the local authority.”

The home raised safeguarding concerns appropriately and arranged meetings with professionals to discuss concerns. Notifications were submitted to the Care Quality Commission to notify us of incidents.

The provider worked with people and their relatives to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A risk management system was in place and risk assessments were held in care plans. These provided staff with guidance on how to manage the risk. For example, one person was at risk of developing pressure ulcers. Staff were guided to monitor the person’s skin and apply prescribed creams. Pressure relieving equipment was in place and a body map was used to inform staff and help manage the risk safely.

Where appropriate, mental capacity assessments were in place to safeguard people’s rights in relation to decisions about any risks.

The provider detected and controlled potential risks in the care environment and made sure equipment, facilities and technology supported the delivery of safe careThe home had fire safety equipment to meet standards and staff had completed the relevant fire training.

The home was clean and free from malodours and designed to be dementia friendly. The windows all had window restrictors in place, and signage helped people navigate around the home.

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

One staff member said, “Although the staff work really hard, I feel that we need a few more staff members on per shift, to support us carers.” Another told us, “We’ve not enough staff on the 2nd floor.” A senior staff member told us, “Levels of staffing do cause us concerns from time to time.” However, the deputy manager told us, “I think we have enough staff, levels have recently been increased.”

Our observations on the 2nd floor confirmed people’s needs were being met, but this floor was much busier than the other 2 in the home. For example, we observed a person waited 13 minutes for support after using their call bell. Support for this person was provided.

Most people told us there were enough staff. Their comments included, “Staff are always busy, but we do receive good care.”

The provider had robust recruitment systems in place to ensure people were supported by staff who were recruited safely. Background checks were conducted to ensure staff were safe to work with vulnerable people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff wore personal protective equipment (PPE) during personal care. Staff understood the need to wear PPE and how to manage the risk of infection. Infection control policies were in place and up to date.

Cleaning schedules were in place and people’s rooms were maintained to a high standard. Toilets and bathrooms were clean and regularly checked.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicine records were not always accurate and up to date. For example, records relating to stocks of controlled drugs were inaccurate with some drugs not accounted for. Some weekly checks of controlled drugs had been missed and the ‘destroyed drugs’ book was incomplete. This meant we could not be assured people had received their medicine as prescribed.

Protocols for as required [PRN] drugs were in place but were not used effectively. For example, one person’s protocol stated, ‘1.25mil-2.5mil’ dosage to support the person when in pain. Records showed the person was routinely given the higher dose with no explanation as to why the lower dose was not used. Another person was prescribed medicine to be administered when they became agitated. However, records did not record the reasons why the medicine was administered or why the person was agitated. This meant people were at risk of over medicating.

People’s medicines were regularly reviewed by the GP and regular audits were conducted to monitor the management of medicines. However, these records were not effective as they did not identify the concerns around medicines found during inspection