Beverley Court Residential 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 service was in breach of legal regulation in relation to the ways people’s medicines were safely managed.

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 management team had a proactive and positive culture of safety, based on openness and honesty. Staff appropriately responded to accidents and incidents, reported them accordingly and kept people’s relatives informed. The management team monitored and investigated accidents and incidents, sharing lessons learnt to embed good practice and reduce the risk of them happening again.

The management team worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They worked with people and relevant health and social care professionals to gather and share information about people’s needs when people moved into or out of the service.

The management team followed their admissions process to gather information about people’s needs which was used to create individualised care plans and risk assessments for staff to follow. For people moving back home or in with relatives, transition plans were implemented and followed with the aim of supporting successful moves. These processes promoted continuity of care when people moved between different services.

The management team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe. One person said, "I feel safe here. I have no issues." People's relatives told us, “[My relative] is safe and happy. That is very important” and “It is important that I am confident that [my relative] is in a safe place and I believe [they are].” Staff had the skills and knowledge to identify safeguarding concerns and reported them internally, though some staff were unable to tell us of external agencies where they could report concerns to if needed. Safeguarding concerns had been appropriately reported to relevant professionals, and action taken to safeguard people.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and whether proper legal authorisations were in place when needed to deprive a person of their liberty. People’s capacity was assessed, though records showed questions asked were not always relevant to the decision being made. Applications were appropriately made to deprive people of their liberty, with records updated following authorisations. Where people objected to the deprivation, staff recorded their objections in line with the DoLS requirements. Staff worked closely with appointed representatives, ensuring they were kept up to date with key information. The registered manager monitored DoLS, to ensure new authorisations were applied for in a timely manner.

The management team did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The management team understood risks to people’s health, safety and well-being and took appropriate action to keep people safe where risk had been identified. However, we found some risks had been overlooked. For example, one person was at risk of urine infections, and the risk of low fluid intake had not been assessed. There was no monitoring in place to ensure the person received sufficient fluids to minimise the risk of urine infections. We raised this with the management team who promptly implemented a monitoring system for this risk.

Personal Emergency Evacuation Plans (PEEPs) were in place to inform staff of the support people needed to evacuate the building in an emergency. We found some were overdue for review and others lacked detail. We raised this with the registered manager who promptly started to review, and update required PEEPs. Staff were trained in fire safety and regular fire drills were held to ensure staff had the skills and knowledge to support people in an emergency situation.

Staff were knowledgeable about equipment people used to manage their safety. We saw safety equipment being used to help manage the risk of falls.

The management team detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The safety of the building and equipment was maintained through the completion of regular checks, maintenance, decoration and servicing.

The management team ensured 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.

Staffing levels were safe and supported staff to meet people’s needs in a timely manner. We received positive feedback form staff about staffing levels. A professional said, “I'm impressed by staffing levels, all have been approachable from what I’ve seen this morning.” Staff were visible throughout the home and had walkie talkies with them, which meant it was easy to find staff when people needed support.

Staff had the skills and knowledge to support people. Staff were positive about the wide range of training they completed which supported them to meet people’s needs. The registered manager kept their skills and knowledge up to date through regular training which meant they were able to support staff as and when needed. Staff received regular support, supervision and appraisals with their competency being checked for key skills such as medication administration. We found some staff skills were not assessed, for example catheter care. However, staff we spoke with were knowledgeable about how to meet these needs.

Systems were in place to ensure the safe recruitment of staff. Appropriate checks had been made to ensure staff were safe to work with vulnerable people, though some reference records needed verifying which we raised with the registered manager. Induction processes were in place to support staff development, with staff’s competency assessed during the probation period.

The management team did not always effectively assess or manage the risk of infection. Most areas of the service were clean and fresh, and staff followed cleaning schedules when regularly cleaning the service. We identified some equipment which had a buildup of dirt and raised this with the management team who arranged for them to be deep cleaned. The management team confirmed new furniture had already been ordered to replace a couple of chairs which had become worn and therefore difficult to effectively clean.

Staff were trained in infection prevention and control and understood isolation processes in the event of an infection outbreak. Staff told us they had plenty of Personal Protective Equipment to be used as needed.

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

People’s medicines were not always stored safely. Some medicines were stored in the fridge however, on multiple occasions, records showed the fridge was above the required temperature. A new thermometer had been ordered, although the risk of continuing to store medicines in the fridge had not been assessed. This meant the management team could not be assured the medicines remained safe and effective to use after potentially being exposed to high temperatures.

Systems in place to ensure the safe administration of medicines were not always followed. We found some hand-written medicine records had not been reviewed and signed by another member of staff. This meant the management team could not be assured the information was accurate and that people were receiving these medicines as prescribed.

Some people were prescribed medicines which needed to be taken at set intervals after their first dose. Staff did not record the time they administered people’s medicines. This meant staff did not know when the last dose was administered and placed people at risk of overdose from their next dose potentially being administered too soon.

Staff knew how people liked to take their medicines and engaged positively with them when administering their medicines. Staff respected people’s right to refuse, documented this and followed processes to return unused medicines.