Bethany 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 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.

The provider was in breach of legal regulations relating to the safety of the premises and equipment and staffing.

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. Management did not always investigate and report safety events.

The Registered Manager kept a log of safety-related incidents; however, these were not thoroughly investigated to identify lessons and prevent similar incidents from occurring again. The provider’s policy was not tailored to the service and did not include clear guidance for the Registered Manager to follow.

Although care plans were reviewed after falls, individual incidents were not investigated to inform and strengthen this process. During the assessment, we observed an incident of poor moving and handling, which we brought to the Registered Manager’s attention. They confirmed that no action had been taken following this incident. However, we did see some evidence of a learning culture, such as minutes from team meetings where safeguarding topics had been discussed.

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.

Clear and accessible information was available to support transitions to other healthcare settings. For example, people had hospital passports in place, which contained essential details about their healthcare needs. These passports helped ensure that important information could be shared promptly and accurately if someone was admitted to hospital from the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly or appropriately.

The service had not always followed internal and external processes to keep people safe. The Registered Manager kept a log of safeguarding concerns; however, they had not consistently responded to these in line with the provider’s policy. For example, they did not identify a safeguarding concern that had been recorded as an individual complaint, and no action was taken to investigate the incident or refer it to the local authority safeguarding team.Staff received training in safeguarding and understood their responsibilities to keep people safe, although some staff had not completed refresher training.

The Mental Capacity Act (MCA) 2005 provides a legal framework for supporting individuals who may lack the ability to make certain decisions for themselves. Under the MCA, people can only be lawfully deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS), which form part of the MCA. We reviewed whether the service was operating in line with MCA principles and how DoLS were managed. Where required, applications had been submitted to lawfully deprive people of their liberty, and staff had received training on the MCA. However, mental capacity assessments were not consistently carried out when specific decisions needed to be made. In one case, a person’s care records stated that, because they were subject to DoLS, all decisions would be made in their best interests. This approach does not replace the need for decision-specific capacity assessments.

The provider did not always work well with people to understand and manage risks. Staff did not always have the correct information to provide care in the safest way.

Risks identified within people’s admission and care plans were not always explored thoroughly through risk assessments, including those relating to alcohol dependency and mental health needs, where no care plans or risk assessments were in place. We also found inconsistencies and unclear information within mobility care plans, falls risk assessments, and moving and handling assessments, with acronyms used without explanation and guidance for staff lacking clarity. Where people required regular repositioning due to risks associated with their skin integrity, monitoring records did not contain sufficient information around the frequency of repositioning.

We did not find any direct impact on people, and feedback from people was positive. One person said, “I get well looked after and I feel safe”. Another person told us “The care couldn’t be better, and the safety is great. I know the staff and they’re all really nice”.

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

The environment was not well maintained and posed risks to people’s safety. We observed areas of disrepair, including damaged flooring, chipped furniture, cracked walls, deteriorated seals in bathrooms, and rusted equipment. Large furniture items were not secured to walls, creating hazards. Security was compromised by unlocked external doors and a cupboard containing high-voltage electrical components. Equipment was poorly maintained; a commode chair was ripped, and an airflow mattress showed a low-pressure warning, and another was overdue for testing. Bathrooms had rusted handrails and broken tiles. Missing flooring in the upstairs hallway was reported to have been present for several months. Some areas were better presented, including the outside seating area.

The provider did not have effective systems in place to ensure 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 have an overarching strategy to ensure sufficient staff were deployed to meet people’s needs. The Registered Manager did not take a systematic approach to determining staffing levels, such as using a dependency tool. Staffing decisions were based on observation rather than a documented process reflecting people’s individual and changing needs. During the assessment, people waited up to 20 minutes for assistance.

Staff told us they generally felt staffing levels were adequate, although shortfalls occurred when staff called in sick at short notice. Comments included, “We have enough staff most of the time but there have been a few shifts lately that were short staffed,” and “Most of the time we have enough staff but when people call in sick last minute it can leave us short staffed.”

The provider operated safe recruitment practices, including disclosure and barring checks, but there were some gaps in records relating to references and interviews. Not all staff had received regular supervisions or appraisals, and some went long periods without recorded support.

Training records showed gaps in mandatory training and expired courses. Only one staff member had completed diabetes training despite some people living with this condition. The Registered Manager acknowledged these gaps and confirmed that following the assessment, 90% of staff had now completed the relevant training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff followed good infection control practices, had an adequate supply of personal protective equipment, and were deployed to clean the home. However, these efforts to minimise the risk of infection were compromised by disrepair in the environment, which prevented effective cleaning. Some cleaning equipment was found to be dirty.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as prescribed. Medicines were administered by trained, competent staff who followed best practice.

Medicines were stored safely, and systems were in place to ensure the return of discontinued stock.

Staff did not record where they placed transdermal patches on the body, which is important to make sure the patches are rotated as prescribed. Instead, staff said they shared this information verbally. We have referred to this practice in the well-led section of the report.