Bethany House

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 service was in breach of legal regulation in relation to people’s safe care and treatment, the way people’s medicines were managed, and the suitability and cleanliness of the environment.

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 provider did not have a proactive and positive culture of safety based on openness and honesty. They did not make improvements where issues were identified. Lessons were not learnt to continually identify and embed good practice.

Management and staff did not learn from incidents where people had experienced harm due to their health. For example, where people’s health had been impacted by dehydration, future monitoring of fluid intake was poor, which placed people at risk of recurring harm.

Accidents and incidents were recorded in multiple locations and information was not always robust or detailed. There was no evidence of meaningful analysis and information prepared for provider oversight was not always complete. This meant lessons could not effectively be learnt to support a culture of continuous improvement.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care.

People had hospital passports in place, which were documents providing a key overview of the person’s health needs to be shared with other healthcare settings when these were accessed. People’s hospital passports were not up to date and did not reflect people’s current needs.

Where people were monitored by other healthcare services, key information was not always recorded by the location following appointments, so the location did not have up-to-date knowledge of people’s needs.

Where recommendations were made by other healthcare professionals, these were not always followed. For example, where exercises were recommended to aid with people’s mobility, these were not taking place or being consistently offered and encouraged. Where recommendations had been made around supporting people’s sensory and communication needs, these recommendations had not always been implemented.

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The manager did not share concerns quickly and appropriately.

There were several safeguarding concerns being investigated at the time of our assessment. We are reviewing these outside of the assessment process.

The registered manager had not reported all potential safeguarding concerns to the provider therefore the provider could not have effective oversight of this. Staff did not always feel the registered manager acted on concerns raised. Staff told us the registered manager ‘took no notice’ and ‘this happened all the time’ when concerns were raised. Staff told us this had changed with the new interim manager and staff told us they now felt listened to and any concerns were acted on appropriately. Further, the provider dealt with concerns raised formally through the whistleblowing process appropriately.

Staff had received safeguarding training, but they had not always applied this training. Staff had failed to escalate concerns when they felt the registered manager had not acted appropriately.

Safeguarding concerns were investigated and reviewed by the provider, but the registered manager did not always report all concerns to the provider, so they were not aware about everything that had been raised.

The service had not focussed on improving people’s lives and ensuring they received the best possible person-centred support which kept them safe and free from the risk of harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not always provide clear and consistent guidance around people’s health needs which put people at risk of harm. There was insufficient guidance and information for staff around people’s physical and mental health diagnoses, and how to safely support these conditions.

The provider did not always complete risk assessments or maintain up to date assessments relating to the health, safety and welfare of people using the service. For example, personal emergency evacuation plans for people were not accurate or up to date which meant in the event of an emergency such as a fire, professionals would not have accurate information to safely support people.

The provider did not provide guidance for staff to enable them to safely support people who communicated distress through behaviours which may be challenging to others. Staff were told to consult a person’s positive behaviour support plan to help them understand and support this person when they may be experiencing distress. However, this plan was not in place. This meant staff did not have information to help them safely manage physical and verbal aggression, such as distraction and de-escalation techniques.

The provider was in the process of rewriting support plans and the guidance provided to staff. The updated and rewritten plans were much improved and contained a good level of detail around people’s support needs.

The provider did not always detect and control potential risks in the care environment. The premises were not suitably maintained. There were various maintenance issues throughout the property including chipped paintwork and holes in the walls. During the assessment, the interim manager identified the maintenance issues, and on our second site visit, the maintenance team addressed these. The provider had identified some of these issues prior to the assessment.

The provider did not always meet people’s needs by way of the facilities available. For example, there was a lack of sensory items for people to engage with and there was a lack of pleasant and usable outside space for people to enjoy. The management team addressed this during the assessment.

In other areas the provider had taken steps to support people to safely access the environment, for example by installing a stair lift for people with mobility issues.

Staff were recruited safely and there was ongoing recruitment to fill several staff vacancies. Agency staff were used in the meantime to ensure appropriate staffing numbers. However, permanent staff told us they were frustrated with the work ethic of some agency staff. One staff member told us, “Agency staff don’t really know what they are doing or know the residents well. They look disinterested and don’t want to be there.”

Staff told us there were not always enough staff to safely support people under the registered manager. However, under the interim manager there were sufficient staff on duty and staff told us they were clearer about their roles and tasks for the day.

Staff received supervisions and generally told us they found these useful.

The provider did not always effectively assess, manage or control the risk of infection. Some areas of the service required cleaning and, on our first site visit, most of the bins in the service were full or overflowing. The service was not well stocked with items such as handwash and paper towels on our first site visit. The interim manager rectified this, and these items were in place on our second site visit. Some staff were not able to competently describe to us safe laundry procedures. The management team completed work with staff to improve knowledge in this area.

The provider did not always manage medicines safely. Keys to medicine cabinets were left unattended in a drawer and in a medicine cabinet itself. This meant there was a risk of medicines being accessed by others.

Where people were prescribed medicines on a ‘when required’ basis, there were not always protocols in place to guide staff as to when these medicines should be administered. This meant people were at risk of not receiving their medicine as prescribed.

Where the administration of medicines was time critical, staff did not record the time a dose was administered. It was therefore not possible to ensure that the required time between each dose had passed. This put people at risk of receiving too much medicine in a particular time period.