Archived: Beech Tree Hall

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.

This service scored 59 (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 reported safety events. Lessons were learnt to continually identify and embed good practice. The management team had systems and processed in place to review accidents and incidents. Actions were taken to mitigate future risks.

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. People had been involved in devising an hospital passport which gave specific information to other relevant professionals as required. These included a short support plan which included information about how best to support and communicate with people. We received positive feedback from external professionals. One professional said, “I have spoken to numerous staff within the home and had two formal meetings with them. I have always found them to be honest and transparent within conversations and if there is anything they are not sure about they will either attempt to clarify or identify the information needed.”

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. The management team and staff recognised and responded to safeguarding concerns and were keen to ensure people were kept safe. Staff received training in safeguarding and understood the process of escalating concerns in a timely way. One staff member said, “If I suspected abuse I would approach my management straight away. I am confident they would take appropriate action. If they didn’t, I would contact CQC, the local council or call 999.” The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. 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 MCA. In care homes, and some hospitals, 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 any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. We found the service was assessing people's capacity to make decisions in relation to their care and treatment. Staff had a good understanding of the MCA and their role in supporting people's rights to make their own decisions. We observed staff offering people choices and respecting their decisions. Where people had conditions attached to DoLS there was a record kept showing that the conditions were being met. One staff member said, “Yes, I have had MCA training. Legislation means to me is to protect and promote human rights for those who lack the mental capacity to consent to their care arrangements like risk getting lost or coming to harm. This is why (DOLS) gets put in place.”

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, and supportive. Risks associated with people’s care and support were identified but not always managed to keep them safe. Risk assessments in place were informative and clearly showed actions taken to mitigate risks. However, we identified a concern relating to a listening device which was used to ensure staff were alerted when people required their support. We found this device was left unattended, which posed a potential risk as staff were not always in that area. Personal emergency evacuation plans (PEEP’s) were in place electronically, to ensure staff knew how to support people to vacate the premises in an emergency. However, grab bags available for evacuation purposes, contained out of date PEEP’s which were not always in line with the electronic copy. This put people at potential risk of harm. The management team took timely action to address these concerns.

The provider did not always detect and control potential risks in the care environment. We carried out a tour of the home with the management team and identified some concerns in relation to the environment. For instance, some radiators did not have covers in place to ensure people were not at risk of burns. Some windows did not have window restrictors in place to reduce the risk of people falling from height. Some cupboards containing staff personal belongings were left unlocked, posing a potential risk to people accessing the contents. We also identified the laundry door to be left open on 2 of occasions, giving easy access to cleaning products. The provider took action to address these concerns. Garden areas were not welcoming spaces where people could enjoy outside space. The provider was in the process of refurbishing the service to improve the design for people living at the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received training. However, supervision sessions had not been held with some staff for a long time. The new management team were in the process of ensuring supervisions took place and appropriate support was given to staff. This was in the development stage and required embedding into practice. However, staff told us they felt supported by the current management team. One staff member said, “I have supervision sessions, and they are supportive, and I do feel supported by my manager.” We received mixed feedback from staff about the way the team worked. Some staff told us they worked together well to provide safe care that met people’s individual needs. Whilst other staff felt communication was poor and some staff did not want to be part of a team. Staff had been recruited safely, and pre-employment checks had been obtained. The provider was in the process of recruiting to vacant positions in the home and using agency staff in the meantime. Agency staff profiles were in place, and the management team requested agency staff who had worked at the home previously to try to maintain consistency. Staff told us they received training to carry out their role.

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. The provider had effective infection control procedures. People were protected from potential crossinfection during the delivery of personal care. Staff received training and were provided with appropriate protective clothing, such as gloves and aprons. We identified some minor infection control issues which the manager took action to address at the time of our visit.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The provider had policies and procedures in place to ensure people received their medicines as prescribed. Staff were trained and competent to administer medicines. People had medication plans in place which gave instruction and direction to staff on how to support people to take their medicines. People who were prescribed medicines on an ‘as and when’ required basis, often referred to as PRN, had protocols in place to ensure safe and appropriate administration.