Beech Hill Grange

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 changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and safeguarding. Insufficient improvements were found at this inspection, and the provider remained in breach of this regulation.
 

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not demonstrate an established learning culture. Opportunities to learn from when things went wrong were therefore sometimes missed.

Systems in place to oversee accidents, incidents and falls were not effective and failed to protect people from harm. We saw weekly reports which gave the provider information about key risks and incidents in the service. However, there was no evidence the provider had used this information to improve safety, reduce identified risks, or embed learning across the service. For example, these reports identified a number of people had nighttime falls. It outlined specific actions to improve safety for people including reviewing equipment and increasing night checks. We did not see evidence the service had implemented any of the recommendations.

The service had made improvements in some areas of auditing following the last inspection. However, we saw the service had failed to identify the risks relating to areas of the premises which could pose a significant risk of harm to people such as combustible items were stored in a locked cage beneath an external metal staircase used as a fire escape route.

Whilst visiting professionals, including nurses and GPs, told us that the home was responsive to people’s changing needs, we found the service did not always manage or monitor people’s safety effectively. We saw evidence of 3 instances where people returning from hospital did not have their care plans or risk assessments updated to reflect their changed needs. This included important areas of support such as the management of pressure care and dietary requirements. Failure to update care plans and risk assessments following hospital discharge places people at risk of avoidable harm, as staff do not have the accurate information needed to deliver safe and appropriate care.

The provider failed to ensure updated information and guidance from partner agencies regarding people’s health and wellbeing was shared with staff. This included information from the speech and language therapy team about One person required a modified diet to manage risks associated with swallowing difficulties. We found people were not always being offered their meals in the appropriate consistency to minimise the risk of choking.

People were confident staff would seek medical assistance when this was needed. We saw evidence that staff contacted out of hours support for people following medical emergencies. However, advice and instructions given to staff following these events was not always checked and shared with all staff in a timely and effective way. For example, The medical team were contacted twice, and different advice was given on each occasion after a person was given the wrong medication. The medical team subsequently provided 2 conflicting sets of instructions. The discrepancy was not clarified or communicated to the staff team, which meant the person was placed at further risk of harm.

Staff told us they understood what their responsibilities were around safeguarding people and had completed online training. However, during our assessment we observed incidents where people had been exposed to potential harm and staff had not recognised, reported or recorded their concerns.

We were not confident the provider consistently took the necessary steps to keep people safe, including addressing concerns and notifying relevant agencies where people had gone missing. We found two recent incidents where people’s whereabouts were unknown for a period of time, creating potential risk. This meant the provider had not recognised or reported potential risks of neglect or unsafe supervision, and opportunities to protect people and prevent recurrence were missed.

We found people who needed assistance of staff to be repositioned to maintain skin integrity were not always supported in line with their care plan. During our assessment we saw a number of people had not been supported with repositioning as detailed in their care plan and were therefore at increased risk of developing pressure sores.

The provider failed to take timely action to address issues raised during the previous inspection. Whilst they had made provision for the storage of hoisting equipment, they failed to ensure the environment was suitably safe and secure for people. These concerns are detailed further in the well led section of this report.

People generally told us they felt safe and trusted staff to look after them, and families told us the registered manager was good and had made some changes across the home. People told us they felt able to raise concerns and most people told us there complaints had been resolved in a timely manner.

The provider 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.

Whilst people and their relatives had access to live care plans, this did not evidence that people or their families were involved in decision making and how best to manage risk. Whilst we saw care plans and risk assessments for people who lacked capacity had mental capacity assessments in place, the best interest decisions were not always person centred, nor did they consider the least restrictive options for people.

We saw records of daily and weekly risk meetings which identified there had been had a number of unwitnessed falls in communal areas of the service. Whilst incidents were recorded, the provider’s documentation did not consistently evidence the actions taken, follow‑up investigations or learning. Further, there was no evidence to demonstrate these events had been discussed with the person or healthcare professionals such as their GP or the falls prevention team. This meant that people were at continued risk of falls which could result in serious injuries.

Staff told us that they had been instructed by a family member to give a person requiring a ‘soft diet’ ’normal’ meals and snacks. A soft diet is when the consistency of food is moderated to enable it to be easier to chew and swallow to reduce the risk of choking. Whilst staff had raised concern the provider had failed to seek further advice from the Speech and Language Therapy (SaLT) team to manage the risk of choking.

We saw staff providing support to people in the communal areas were not able to access detailed care records and risk assessments for everyone living at the service. Staff told us they could only access the records for the people on the unit they were allocated to work. The records we looked at confirmed this, which meant staff were at risk of not being aware of changes in a person’s needs such as a decline in their mobility.

Therefore, the provider could not be assured support given by staff was safe. This was somewhat mitigated by the fact that staff knew people well.

The provider did not always detect and control potential risks in the care environment.

The provider had taken action to improve some areas of the care environment including storage of hoists and staff were now trained in fire safety and the training compliance was at 91%. However, during our assessment, we found a window on the ground floor without restrictors fitted which opened onto the garden. We were told there were people living at the service who may attempt to leave the premises unnoticed. There was no risk assessment for this window along with consideration of who may have access to it.

A gel air freshener had been left out on top of a cupboard in an area where a number of people living in the service had a diagnosis of dementia and could walk around without support. We found Combustible items were stored in a locked cage beneath an external metal staircase used as a fire escape route which had not been identified in environmental or fire safety audits completed by the registered manager. Due to the location and items stored, this was a continued fire risk from the previous inspection. We showed the registered manager this who had the items removed immediately.

We saw the environment was clean and maintained to a good standard and people had the equipment they needed to support their mobility and safety. Most people and relatives told us they were happy with how the facilities in the home were maintained. They told us they felt the home was maintained to a good standard and supported people to live there safely.

The provider did not always make sure staff received effective support, supervision, training and development.

The provider had robust recruitment systems in place to ensure people were supported by staff who were recruited safely. Appropriate background checks were completed prior to employment, helping to ensure staff were safe to work with vulnerable people.
Staff who had recently joined the service told us that their induction experience had been positive and had spent time working with others before working on their own.

Staff told us they provided a lot of support to people who were in receipt of end-of-Life care. Some said they felt they could benefit from additional training as the current online training did not give them enough confidence in meeting people’s needs at this stage of their life.

We shared this feedback from staff with the registered manager who told us they would look into this further.

Staff were not always supported effectively to carry out their roles.

Some staff had not received regular supervisions or appraisals, and not all training was up to date. This meant the provider could not be assured that staff were consistently following best practice or working safely.
People told us they felt there was enough staff on duty most of the time to support their needs.

Review of staff rotas showed consistent staffing levels with minimal reliance on agency staff.
 

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

During our assessment we saw that there was a high number of people being treated for a chest infection. Two people had recently passed away while being treated for respiratory infections. Although there was no confirmed outbreak, the provider’s own clinical risk meeting identified a heightened risk and recommended IPC and ventilation actions, which had not been implemented.” However, an outbreak had not been identified by the registered manager or notified to the appropriate agencies. We reviewed weekly reports which had highlighted the increase to infection levels. The provider has not considered, or taken, appropriate steps to mitigate the risk of infection spreading, such as increased ventilation, enhanced cleaning, social distancing in communal spaces and the use of personal protective equipment (PPE).

Although there was no confirmed outbreak, the provider’s own clinical risk meeting identified a heightened risk and recommended IPC and ventilation actions, which had not been implemented. “We did not witness any additional measures being taken by the provider at this time in response to the ongoing outbreak. We discussed this with the registered manager who then took action to report the outbreak to health authorities. This meant people and staff were not protected from the risk of infection.

We saw that PPE was not always disposed of safely. We found a used glove on the floor in a communal area outside one of the bedrooms.

There was a nominated champion for infection prevention and control (IPC); however, documents and policies detailed that positions were vacant which may lead to confusion amongst some staff as to who was fulfilling this role. The staff we spoke with were not always about who was the service’s IPC champion.

People and their relatives told us they were happy with the cleanliness of their home. We saw the home was clean, tidy and uncluttered. The décor was generally well maintained as were the gardens. People told us when they reported something in need of repair, it was fixed straight away.

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

Nursing staff and trained medicines technicians were responsible for supporting people with their medications.

Staff told us they received regular training to administer medicines and had their competencies assessed. However, we found people’s medicines had not always been well managed.

Staff told us they were regularly interrupted during medication rounds to answer call bells and take phone calls which could be distracting.

We reviewed medication administration records and found people were not always being supported to take their medicines as prescribed.

Some people had missed doses of their prescribed medicines for periods of time. One person had gone without a medication they were prescribed 4 times per day, for 3 days. In addition to this, they had been given too many doses of another medication.

Both of these incidents placed the person at significant risk of harm.

The provider is responsible for ensuring people have access to their medicines as prescribed to ensure people’s needs are met and to try to prevent deterioration in their health or well-being.

People had not been effectively protected from this potential risk at this time although we found no evidence that people had experienced harm as a result.

Systems for managing medicine stock delivery and ordering had failed to ensure that people did not run out of medication.

Effective systems were not in place that would alert staff when a particular medication was not available or the service was running out of stock. This meant that there was a continued risk for people to make mistakes.
We brought these matters to the attention of the provider and registered manager and shared our concerns with the local authority safeguarding team. The provider told us these concerns would be looked into.
We observed some good practice when people were receiving their medicines. However, we observed a person who was receiving support with prescribed creams administered to their legs was supported at the table in the dining room at mealtime.

This was not appropriate, as it did not promote the person’s dignity, their privacy was not respected and the application posed potential hygiene and infection control risks within the communal dining area.
We saw the GP and pharmacy reviewed each person’s medicines regularly to monitor the effects on their health and wellbeing and give advice to people and staff about their medicines.