Betsy Clara Nursing 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 regulations in relation to infection control and safe and effective 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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and report safety events. Lessons were learnt to continually identify and embed good practice. The provider had a process in place to ensure lessons were learned across the service when incidents and accidents occurred.

For example, staff had all recently had moving and handling training refreshers following an incident. Staff were also reminded to challenge poor practice. Notice boards in staff areas clearly detailed information about learning from events such as information published by CQC about protecting people who use wheelchairs.

Staff told us that accidents/incidents and changes to people’s health was discussed in handovers. Relatives told us they were made aware of incidents and accidents when they happened. A person told us, “Someone fell on me. The staff did all sorts of things (in response to this).”

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. A relative said, “I can’t fault the transition from the previous home to here.” When people were supported to go to hospital, either through routine or planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from staff who they know well to understand what was happening. People and relatives told us the GP visited regularly.

The service had maintained regular contact with local authority social workers. This included ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP. A healthcare professional told us, “I have seen that the staff have referred the residents to SALT (speech and language therapy), TVN (Tissue viability nurse), podiatry, GP, MHT (mental health team) in a timely manner.”

A relative detailed how their loved one had been moved to the service safely. They explained that the registered manager visited them at their loved one’s previous home and systems were put in place to enable a safe transfer from one care home to another.

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 were safe and were protected from harm. Staff were aware of the whistle blowing policy and told us they always had access to all policies. We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted.

Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. A staff member said, “I would report (abuse) to my line manager. If the manager is involved, escalate higher or contact CQC or safeguarding.” Another staff member told us, “Safeguarding training is online, I would do an incident form, report to management” and “The manager will escalate it. It would be taken seriously, I could report to CQC or to social services.”

Relatives and friends told us their loved ones were safe. We received mixed feedback from people. People told us, “I feel safe, the staff are wonderful” and “I do not feel safe. The floors aren’t safe for me, they are too slippery.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Risks to people in relation to harm from constipation were not always well managed. For example, action had not always been taken to give people as and when required laxative medicines when they were suffering from constipation. Some people had not opened their bowels for many days (this varied between each person from 4 days up to 14 days). This had not been reported to the GP and actions had not been taken. We reported this to the registered manager, they took immediate action, people who needed it were given laxative medicines and the GP was contacted. We also reported this to the local authority safeguarding team. After we raised this, changes were made to care plans and risk assessments to make it clear to staff including nursing staff at what point constipation should be escalated to the GP. Processes were changed immediately to ensure that there was sufficient oversight daily of people’s constipation.

Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. Not all people’s PEEPs included risks of wearing flammable creams. This was rectified for each person on day 1 of our assessment visit.

Staff used an electronic system of care planning which promoted staff to undertake tasks. There was sometimes conflicting information about health diagnoses and choking/swallowing risks through the care plans. Some care plans and risk assessments lacked some information, and the quality of care planning was varied. For example, risk assessments were not clear around epilepsy risks. A person’s care plan detailed they had a catheter; however, they did not have this any longer and the care plan and risk assessment had not been updated. Moving and handling assessments were not clear about slings which were used when people were hoisted. Amendments were made to risk assessments immediately to prevent people from coming to harm.

Relatives told us their loved ones were safe, and risks were managed. We observed staff supporting people to manage risks throughout the assessment.

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

A redecoration programme was in place, some rooms and areas had yet to be completed. People had not been involved in choosing the colours of their rooms. The provider had opted for a beige/cream colour scheme throughout the service. Some parts of the service looked tired and tatty. A relative told us, “The home doesn’t look polished, but it has good care and warmth. Dad’s curtains were tatty, they have been changed.”

Other maintenance tasks appeared to have been completed in a timely manner. Rooms were tidy and had been personalised in accordance with the person’s wishes. Fire exits were clearly visible and unobstructed. The lift was clean and in working order.

The provider made sure there were enough qualified, skilled and experienced staff. However, they had not always received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff had not always received training to meet people’s assessed needs. The training matrix showed that most staff had completed mandatory training. However, the records showed that the majority of staff had not completed additional training to meet people’s assessed needs; only 4 staff out of 70 had completed diabetes training, only 4 had completed epilepsy training, only 5 staff had completed skin integrity training, no staff had completed catheter care training or Parkinson’s training and 4 staff had completed ‘Understanding and Supporting Individuals Living with Dementia.’ The registered manager told us that staff had however completed dementia experience training. Whilst the risks of staff not knowing fully how to meet people’s needs were partially mitigated by having trained nurses on shift, there was a risk that staff may not recognise changes in people’s health that could be linked to diabetes, epilepsy, skin integrity, catheter care and Parkinson’s disease. Only the registered manager had completed specific training relating to learning disability and autism, despite staff supporting a person with a learning disability at the service. CQC registered providers must ensure their staff receive learning disability and autism training that is appropriate to staff members roles. The registered manager told us further training was going to be rolled out. They said, “We have added dementia awareness, and Oliver McGowan (this is autism and learning disability training) for all staff, diabetes, epilepsy, catheter care and Parkinsons training for all care and nursing staff.” Whilst we had not identified any direct impact to people in relation to this, risks of not meeting people’s needs safely were identified. Staff told us “We had training last month regarding behaviour and how to react, it was good to do, and I learnt something new” and “Training is provided annually (online and occasional face-to-face).”

Staff had regular supervision meetings, induction was a mixture of training and shadowing experienced staff to gain confidence and experience. Staff gave us mixed feedback about their inductions. Some staff said it was good, and they were given time to get to know people and their routines. Others said that it was rushed, and minimal time was given to shadow experienced staff and to learn about the service.

We observed there were enough staff on duty to support people. We observed call bells were answered quickly. However, before, during and after the assessment visit we received whistle blowing information from staff about the inadequate level of staffing. We reported this to the nominated individual for the provider, who carried out an investigation. The nominated individual fed back to us at the end of the investigation, they told us they found no evidence that the level of staffing was inadequate. They said, “We then have 15 staff for 41 residents. So, 3 residents have one-to-one care, then 38 residents have 12 staff looking after them (2 nurses and 10 carers). That is a ratio of 3.2:1. That is extremely high staffing.”

Staff commented, “More staff are needed, we have spoken to management about this, and it was dismissed”; “Consistently short-staffed on own shift; unclear about others. Management claims staffing is adequate, but staff disagree. Reports to management haven’t led to improvements” and “To be honest I think we are understaffed to be able to meet resident’s needs, some are very challenging. A little time ago it was unmanageable, the allocations are confusing. For example, if a resident has 1 to 1 care and support at night and the staff member needs to take a short break to use the toilet or get a drink, I need to support them and take over. It takes time away from other people who need help.”

People told us, “There are enough staff, couldn’t comment on nighttime, I sleep well” and “There’s enough staff. They are available if you ring your buzzer.” A relative said, “There should be more of them (staff) about. I understand the costs and everything but there should be more here. The staff don’t go in and chat with people in their rooms, only the ones in the lounge. I wish they would go in and chat with [person].” Another relative told us, “I feel they need more staff at the weekend.”

Staff had been safely recruited. All required recruitment checks had been carried out and documents were all in date. The provider had retained copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council. The provider had made checks on their personal identification number, registration status and renewal date.

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.

We observed some areas of the home had not been effectively cleaned. On the first day of the assessment the lounge carpet on the ground floor was extremely dirty, the corridors floors were sticky, and people’s shoes were sticking to them. Some carpets and flooring in rooms were stained and dirty. We reported this to the nominated individual for the provider. They arranged for staff to clean the lounge carpet and arranged for a flooring company to come in and measure up flooring in other rooms. On the second day of our assessment, the lounge carpet was clean, and the corridors were less sticky.

There was a strong odour of stale urine in 2 areas of the service. This was present on both days of the assessment. Some relatives told us about this too. A relative said, “The men’s unit smells a bit of urine.” However, people told us the service was clean. Comments included, “The home is kept clean” and “The minute we step away from a table, it’s cleaned.” A visitor said, “They’re very good at keeping her room clean.”

The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. We observed that the staff were using PPE effectively and safely. Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. Staff told us, “Training is ongoing and reinforced. Staff not wearing PPE are spoken to immediately” and “PPE is always worn. If not, management would address it.”

The provider did not always make sure that medicines and treatments were safe and met

people’s needs, capacities and preferences. The provider had systems and processes in place to manage medicines, these were not fully robust, and some improvements were identified. People had not always been given PRN (as and when required) laxative medicine when they were constipated. The medicines administration record (MAR) showed that nursing staff responsible for administering medicines had been recording ‘not required’. We asked nursing staff who administered medicines during a medicines round how they knew people did not require their PRN laxative medicines. A nurse told us, “If they were constipated, the night nurse would have handed it over.” Bowel monitoring records had not been checked prior to making these judgements. There was no oversight of bowel records. We reported this to the registered manager on 02 September 2025, during the night of 02 September 2025 into 03 September 2025 each person’s bowel records had been reviewed by nursing staff and notes made in the handover records as to who had opened their bowels or not. Some people were given laxatives as a result of this exercise.

Medicines administration records (MAR) were clear. For medicines given ‘as required’ (PRN), such as pain relief there were protocols in place. Room and fridge temperatures were recorded to ensure medicines were stored at the correct temperatures. The fridge temperatures checks did not follow good practice guidance. We provided the registered manager guidance about recording maximum and minimum temperatures of medicines fridges.

Medicines were securely stored and timed medicines were given appropriately. The ordering process for prescribed medicine was effective, and we were able to reconcile medicines stock with prescribing. The management team carried out regular medicine audits. We observed people receiving their medicines safely. The registered manager and nursing staff told us that medicines were reviewed regularly and there were procedures in place to ensure people were not over prescribed antipsychotic medicines. A nurse told us, “There are people who are prescribed antipsychotic medicines, these are given as a last resort after trying everything else.”