Bentley Court 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 service was in breach of legal regulation in relation to staffing levels in the service.

This service scored 56 (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 learning culture. Where the provider had identified concerns around people’s choice and individual preferences not being consistently met, these concerns had not been successfully addressed and remained a concern at our inspection. This placed people at risk of receiving care that did not protect their rights. However, leaders told us about the systems in place to learn from incidents, all incidents were reviewed, and learning was drawn from them and shared with staff. We saw tools were in use to examine accidents and incidents, falls, safeguarding and complaints and root cause analysis processes were also used. We saw where people had falls actions had been taken to reduce the risk of reoccurrence. Partners confirmed the provider thoroughly investigated any incidents, to identify areas for improvement and sharing of learning with the staff team.

The provider did not always manage or monitor people’s care delivery to ensure safety. They did not always ensure people received care at the right intervals in line with their assessed needs and care plan. For example, people had their personal care needs met at varied times. Where people required support with repositioning this was not always done in a timely way following the intervals suggested in the care plan. The provider had however worked with healthcare partners to establish and maintain safe systems of care. People had input into their assessments and care plans from a range of different health professionals and this was used by staff to guide how to support people.

The provider 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 and their relatives confirmed people felt safe and were receiving safe care. One person told us, “It’s very nice because they look after us so well. The staff are very good and always there for you.” Leaders understood the local safeguarding procedures and could demonstrate how they had made referrals to the appropriate body when incidents occurred. Staff understood how to recognise abuse and reported any concerns. Applications were made to the authorising body for a Deprivation of Liberty Safeguard where required and any conditions required were met.

The provider did not always ensure staff provided the care people needed to maintain their safety. People did not always have their risk assessments followed. For example, one person’s care plan stated they should have a sensor mat in place, at the side of their bed, to protect them from the risk of falls. We saw the sensor mat had been moved from the side of the persons bed and was not plugged in leaving the person at risk of having a fall. However, we saw people had risks related to distressed behaviours assessed and plans put in place to support staff to help people when they became distressed. We also saw people had risks to their skin integrity, nutrition and hydration needs and mobility needs assessed and plans were in place and followed by staff.

The provider did not always ensure the equipment, facilities and technology supported the delivery of safe care. We observed some equipment in place to support people to manage risks of falls was not operating and was faulty. This had not been identified, and action taken to repair or replace the equipment. We found an air mattress had an alarm sound going off all day indicating the mattress had low pressure. There had been no action taken to address this. The provider took prompt action to address these concerns when we highlighted them. The provider did have systems in place to ensure they detected and controlled potential risks in the care environment with regular safety checks completed. However, these were not always effective. We saw certification in place, to confirm utilities and equipment were safe to use and regular checks on fire safety had been completed.

The provider did not ensure there were enough qualified, skilled and experienced staff. Relatives felt there were times during the day when there were not enough staff to support people including weekends and during mealtimes. One relative told us, “The staff are very friendly and very nice, although I do think you could do with some more staff. It would be nice if they could sit down and chat with [person’s name] for 10 minutes.” We saw call bells and bed sensors which were left for over 10 minutes unanswered. We saw some people had no engagement and encouragement at lunchtime as there were not any staff available to offer this. Staff had mixed views about staffing levels with some staff feeling they could do more to support people if they had more time. We saw staff were deployed to support people following a task list to meet people needs. This meant staff were not always deployed to support people when they needed it. However, staff received effective support, supervision and development opportunities from the provider. We found staff were recruited safely with checks on their suitability to work with people in place and had a clear induction into the role. Staff had access to supervision and meetings to offer support in their role and regular updates to their training was offered.

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. People and relatives raised no concerns with us relating to controlling the risk of infection. Staff were observed following safe infection prevention control measures including using personal protective equipment. Processes were in place to assess risks in relation to the spread of infection and we saw the provider had taken the required steps to minimise risks and check staff were following safe procedures.

The provider had not ensured all medicines were stored safely. We found some prescribed topical creams were not stored in lockable facilities and were kept in people’s rooms. This placed people at risk of harm. The manager took immediate action to address this and secured the medicines safely. However, people were receiving their medicines as prescribed, and staff were administering medicines safely to meet people’s needs and preferences. Staff involved people in planning, including when changes happened. People told us they received support with their medicines. One person told us, “I always get my medicines on time and there are no problems.” People had assessments and care plans put in place to support safe administration of their medicines. Staff were observed ensuring the medicines policy was followed and all medicines were administered as prescribed with administration records accurately completed. Staff followed the guidance in place for safe administration, including when people were receiving as required medicines.