Beech Haven

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 has remained 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 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were suitable systems for learning when things went wrong. Following any accidents or incidents, the staff recorded these and they were investigated. The provider had a clear system to record accidents and incidents, these were audited and lessons learnt were shared at team meetings.

Staff knew and understood the process of reporting incidents, accidents and safeguarding concerns. There were suitable systems for learning when things went wrong. Staff told us the management team informed staff of incidents and accidents at team meetings and also received notifications on their mobile device so that they could be updated immediately when on shift.

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

The provider had systems and processes to support safe admissions and transfers of care. The registered manager assessed people before admission to ensure the service could meet their needs.

Staff were informed of people’s needs through electronic care plans and handovers. A member of staff told us, “Generally, care is assessed and put on a care plan on admission. There is sometimes a care plan or an assessment by the hospital we can look at that too.”

A person told us, “I’ve only been here a couple of months, but I’m happy with how things are going. The communication between the services is frighteningly good, at least in my case. They are meeting my needs at the moment.”

The provider did not always share concerns quickly and appropriately. We found there was not a strong understanding within the management team of what needed to be reported to the local authority and CQC. For example, we identified incidents where people had experienced unwitnessed falls that should have been reported to the CQC but were not. Following our assessment, the provider has since begun notifying the CQC of relevant incidents.

Although we found shortfalls, people and their relatives told us they felt safe and we observed mostly positive interactions between people and staff. Their comments included, ‘’I think it is OK. It’s nice. There is nothing to worry about. There is a bell in my room in case something happens. I’ve used it once or twice – I think they came along quickly. I’ve not had any falls. I think the carers know what they are doing.” Another person told us, “I feel safer here than at home, I came here from hospital. I’m here, if anything else happens I know there are carers around to help.”

There were suitable systems for safeguarding people from abuse and mistreatment. Staff received safeguarding training and had a clear understanding of the signs of abuse to look out for as well as the principles of the Mental Capacity Act 2005 (MCA).

Staff confirmed there were team meetings to discuss what had gone wrong and to discuss the need for good practice. An example given, was the management team reminded staff to encourage people to drink fluids during hot weather and for staff to accurately record their fluid intake.

Staff assessed risks associated with people’s health conditions, activities and lifestyle choices. These assessments gave guidance for staff on how to mitigate risks. However, they had not always been updated with changes in people’s needs. For example, we found that a Personal Emergency Evacuation Plan (PEEP) was not updated to reflect a person’s current mobility status, we also found that a front page of another care plan did not include current information regarding a person’s mobility. The issues we found on this assessment had not been identified through the registered manager’s audits.

While no evidence of harm was found, risk assessments were not always current. Nonetheless, risks were generally assessed and reduced, and individual risk assessments included clear guidance for staff to follow.

The environment was not always safely or well maintained. The fire risk assessment had not been reviewed since August 2022. The overhead extractor fans in the kitchen were visibly dirty, with a significant build-up of grease. Fire safety equipment in the kitchen was also dirty, including fire extinguishers coated in grease, which could compromise their effectiveness in the event of a fire. Additionally, there was a lack of adequate fire exit signage throughout the home, which could place people at significant risk during an emergency.

Environmental risks also included the absence of risk assessments for stairways and windows fitted with restrictors. While the provider conducted audits of the home, these were not always effective and failed to identify several of the issues we noted during our assessment.

Since our last visit, some improvements had been made to the interior environment. For example, toilet and bathroom doors had been painted yellow to support dementia-friendly design. The home was generally clean, and people and their relatives gave positive feedback about cleanliness. However, some areas showed signs of wear and tear and were in need of refurbishment. The registered manager told us there was a plan to redecorate the home, and that this plan would be shared with us. At the time of writing, we had not yet received it.

We were not assured that all staff had completed the required training necessary to ensure they had the skills and knowledge to provide safe and effective support. Training records showed that not all staff training was up to date. For example, 5 members of staff had not completed adult safeguarding training, with 1 staff member last completing this training in 2015. Additionally, 5 staff members had out-of-date medication administration training, with 2 having not received any since 2019. This posed a risk that people may be supported by staff who did not have the necessary skills or up-to-date knowledge.

Despite these gaps, the provider ensured that there were sufficient experienced staff on duty who received regular support, supervision, and development. Staff worked well together to deliver care that met people’s individual needs safely.

Staff told us they felt staffing levels were adequate and that they supported one another during staff absences. 1 staff member commented, “Yes, there are enough staff, we are not rushed. If someone is off sick, we will cover their shift. If staff are sick, the manager usually gets someone else in, but if not, we will cover, it’s teamwork.”

People using the service and their relatives also gave positive feedback about staffing levels. 1 relative said, “I’m reasonably happy with things. I think my relative is safe enough. The staff are friendly and there are always staff around. They seem to know what they are doing.”

The provider did not always assess or manage the risk of infection. We found people were not protected as much as possible from the risk of infection due to equipment not being

kept at a clean and hygienic standard. Food contents in communal fridges were not labelled with expiry dates and we found expired food in the fridge.

Laundry was divided into soiled and unsoiled items to avoid cross contamination and put in a lidded trolley. There were PPE stations on the corridor with, aprons and gloves for staff

use. Hand wash posters and reminders to wash hands prior to touching equipment were displayed as reminders throughout the home. People told us they were happy with the cleanliness of the home and that staff used PPE when supporting people with personal care. Comments from people included, “The cleaning is good. They wear gloves and aprons for personal care.” and “I’m happy with the cleaning and they always use gloves and aprons for personal care.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Audits of medicines management was not being conducted effectively. Staff told us medicine audits were completed monthly; however the most recent audit we saw had been completed in November 2024.

Medicines were stored safely and securely, including controlled Drugs (CDs). Staff checked and recorded ambient room and fridge temperatures of the medicine’s storage room daily. There were protocols available to guide staff on how to manage ‘when required’ medicines.

People told us they were happy with the support they received with their medicines. We observed a medicine administration round and saw that people were given their medicines appropriately and as prescribed. Comments from people included, “Medication is always on time. The most recent prescriptions were given by the pharmacy at the hospital. I have to say that they are very thorough about that. I have even got the names of every drug I take. The communication between the hospital, pharmacy and the home has been amazing.” Another comment was, “They take the medications very seriously; I know what I take and it’s always on time.”