Beechmore Court

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 inspection we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 told us they were able to raise issues and learning was shared. The registered manager had good oversight of accidents and incidents, complaints and falls and there were systems in place to take prompt action and identify themes. Reports were shared and discussed at senior management meetings for added oversight and learning.

Staff and managers described using feedback to drive improvements. For example, the service responded to recommendations from a local authority quality assurance visit to improve medicine records. At the follow-up visit the service received very positive feedback with no recommendations, showing the registered manager and staff had acted on and learnt from the feedback received.

Professionals told us the staff were proactive in learning from concerns, with one professional explaining, “I have always found them to take any appropriate action with any concerns although I have to say there haven't been any great concerns over the years.”

The provider ensured systems and equipment supported safe pathways. The provider showed effective systems for managing safe care and supporting people through transitions. Assessment processes were thorough, with clear, detailed assessments prior to admission. Transitions into the service were well planned and person centred.

External professionals told us staff were proactive in managing changes in people’s needs and arranged multi-disciplinary meetings where needed. The service supported people to remain in the home wherever possible. One professional told us, “They ensure people can stay even when needs change. Being able to stay in the place you know has real impact on quality of life.” Information shared with professionals during visits and handovers was detailed and accurate. The service also worked in partnership with external health professionals to manage safe admission into and out of hospital.

There were clear processes in place to protect people from avoidable harm and a culture where staff felt able to speak up and report concerns. Staff received regular safeguarding training and spoke confidently about be able to raise concerns if they needed to. One member of staff told us, “I have raised concerns about one person’s potentially inappropriate behaviour. The registered manager responded and the behaviour was managed effectively.”

People and relatives consistently said the service kept people safe. One person told us, “I feel very safe here, there is no one that I don’t trust.” A relative said, “We have never had a worried moment since [family member] came here.” Professionals told us staff were “exceptional” in ensuring prompt action and supporting people’s safety.

The service involved people and families well in managing risks. There were clear, detailed and personalised risk assessments that were regularly reviewed and supported positive risk-taking. People and relatives told us staff understood their risks, with one person saying, “They really took the time to understand the risks and come up with practical ways to reduce them.” Staff identified early signs of deterioration and escalated concerns appropriately. External clinicians confirmed staff were skilled in managing risks and “very good at voicing any concerns” and acted promptly to seek additional clinical support when needed. One professional told us, “I know they are efficient when responding to falls risk and preventing pressure ulcers. If a pressure ulcer is to occur, they are very efficient at ensuring pressure relieving strategies.”

People lived in a safe and well-maintained environment. The provider detected and controlled potential risks in the care environment and made sure equipment, facilities and technology supported the delivery of safe care. When hazards had been found, the provider had addressed these. One member of staff said, “Action is taken immediately to rectify any environmental or building maintenance concerns. If beyond our ability, external contractors are contacted to resolve.”

During the assessment we found hot water monitoring was happening every three months which is not in line with current best practice. Based on our feedback the provider has increased the frequency of checks to monthly which is more in line with current standards.

Staff kept a live repairs log and used group messaging to ensure issues were tracked until resolved. There were also regular health safety meetings which were attended by staff from across the service where ongoing maintenance issues and routine works were discussed. There were fire safety plans in place, and regular checks of equipment to help detect and prevent fires. The provider was working through actions identified during the most recent fire risk assessment.

The provider made sure there were enough qualified, skilled and experienced staff. Despite generally robust recruitment process we found recruitment checks required improvement in some areas. We found that while recruitment checks were mostly well documented, the provider had not obtained a full employment history for all staff. We discussed this with the provider, and they have resolved the gaps we found and carried out a full audit of all staff records.

Staff received an induction, regular supervision and appraisal and ongoing training to ensure they could deliver safe, person-centred care. The provider used a range of different training methods to deliver training including e-learning, face-to-face training, self-directed workbooks and mini learning sessions. Staff were consistently positive about the induction, training and ongoing support they received. Comments included, “I found the induction informative” and “The training I receive is very useful and helps me to do my job safely and properly.” People and external professionals praised the skills of staff. Comments from people included, “They know their stuff” and “They seem to me to be well trained.”

The provider assessed and regularly reviewed staffing levels to ensure there were enough staff to deliver safe and effective care. We saw that there were enough staff to support people on the days of our visits. People did not have to wait for care. Staff were attentive and responded when people needed support. Feedback from people and staff confirmed this. One member of staff told us, “The staffing levels are good and there is always enough staff.”

The provider had an effective approach to assessing and managing the risk of infection, with policies and training aligned with current best practice guidance. We found the home to be clean and hygienic throughout which aligned with feedback we received from people and relatives who described the home as “immaculate,” “spotless” and “beautifully clean.” People and relatives also reported consistent use of personal protective equipment, including gloves, aprons and masks when needed. Visitors were asked to wash their hands before entering which reduced the risk of infections being brought into the home.

Staff had clear roles and responsibilities around infection prevention and control (IPC), which enhanced the overall safety and well-being of people who used the service. One member of staff told us, “Cleaning is very important in a care home. I always follow infection control procedures and make sure areas such as people’s rooms, bathrooms and communal areas are kept clean and safe.”

Medicines were stored, monitored and administered safely. People told us they trusted staff with their medicines, and they were given at reliable times. Comments included, “I am sure they are given correctly, I check on my book sometimes” and “They come at the same time every day which is good enough for me.” We received positive feedback from professionals who supported the service to manage medicines which corresponded with what we found.

Staff were trained and assessed as competent to manage and administer medicines. We saw that staff gave medicines to people in a caring and dignified manner. Medicines administration records (MARs) were completed accurately and audited to identify errors. The registered manager investigated any errors and resolved these to minimise the risk of similar issues occurring again.