Beechcroft

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.

This is the first assessment for this newly registered service. This key question has been rated 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 safe care and treatment.

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 did not always have a proactive and positive culture of safety. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff recorded incidents, including near-misses and physical violence towards staff, within people’s individual care records. However, there was no system in place to identify them as incidents or to review them on a regular basis to identify opportunities for learning. This meant opportunities were missed to mitigate future risks and to improve the care people received.

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.

The registered manager completed pre-assessments prior to admitting people to the service which ensured their needs could be met. The service worked well with local healthcare providers and had good communication systems in place, for example regular reviews with the local GP practice.

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.

Staff understood what safeguarding was and systems were in place to notify the local authority and CQC in line with legal requirements. All the staff we spoke with demonstrated an understanding of safeguarding processes and the role they played. Staff were confident raising concerns. One staff member said, “I am encouraged and supported to raise any concerns”.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that systems were in place to assess people’s capacity and DoLS applications had been made where appropriate to do so. Staff supported people in the least restrictive way.

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.

People’s risks were assessed, and care plans included some detail about how staff should support people to manage their risks safely. However, care plans relating to specific medical needs were not detailed enough and did not give staff specific direction about how to support the person, or what signs to look out for and what action to take if something went wrong.

Systems in place to monitor people’s risks were not effective. For example, people identified as being at risk of dehydration had fluid monitoring records in place, but those records showed a very low intake of fluid on some days, which indicated people were not having enough to drink. People identified as being at risk of constipation also had monitoring processes in place, but there was no evidence staff used these records to ensure effective oversight, and the information wasn’t communicated from one shift to the next. This put people at risk of harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Systems were in place to ensure routine maintenance and servicing took place and equipment was safe to use. Environmental risk assessments had been completed and there was a programme of planned work, for example, work had recently been completed to improve the effectiveness of the fire doors.

During our site visit, we raised concerns about the temperature and quality of some metal radiator covers, and the risk of falls from height from the balcony area. Staff immediately updated risk assessments in relation to these concerns and informed us that rusted radiator covers would be replaced.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

The provider did not use a dependency tool to calculate staffing levels based on people’s individual needs. During the afternoon, there were usually 6 members of care staff on duty, plus management and ancillary staff. At 7.30pm this reduced to 2 staff until 7.30am the next day. When we asked the registered manager how they knew it was a safe staffing level, they told us, “It’s just the way the night shift works”. Records showed there were many incidents at night, including falls, and people being found in each other’s bedrooms. No analysis had been done to ensure there were sufficient staff on duty to both meet people’s planned care needs and respond to incidents.

Staff told us there were generally enough staff on duty, with the exception of short notice sickness. One staff member said, “Most of the time staffing levels are good, but when we are short, it can be challenging”. We received mixed feedback from people’s relatives in relation to staffing levels. One person’s relative said, “There always seems to be a lot of staff and most of them have been there a while”. Another relative said, “There should probably be more staff”.

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

We had received concerns relating to infection control and management of hygiene in advance of this inspection. Some relatives told us people’s continence needs were not always well managed or promptly met. During our site visits, we found most areas of the home were clean, hygienic and free from offensive odours. However, there were some bedrooms that fell below standard. For example, 2 bedrooms smelt strongly of urine and one had food trodden into the carpet and ingrained into the chair. We received feedback from some people’s relatives their rooms had occasional odours and unpleasant stains, however other people’s relatives told us they were impressed with the cleanliness of the home.

Communal areas were clean and tidy. Laundry was managed in line with infection prevention and control best practice.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

People did not always receive their prescribed creams. The system for recording prescribed creams was not effective, and it was not possible to see which creams had been administered, when. There were not always clear directions in place to tell staff where to apply cream, and the records had gaps in them. This put people at risk of skin damage. The provider made changes to the system immediately after our site visit, to address this concern.

All other prescribed medicines were administered safely. Staff had completed training, and records supported the safe delivery of medicines.