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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 improved the culture within the service so there was a proactive and positive culture of safety, based on openness and honesty. The provider, management team, and staff had learnt from the previous assessment findings. Learning was an ongoing focus, and staff were encouraged to speak up and report any safety concerns. The provider ensured there were multiple ways staff could raise issues, which helped to prevent a closed culture developing at the service. Accidents and incidents were dealt with appropriately, and lessons learnt from incidents were relayed to staff in meetings, handovers and supervisions.

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 provider had reviewed and updated people’s hospital passports. This was a document which provided a key overview of people’s health needs to be shared with other healthcare settings when these were accessed. People’s hospital passports were up-to-date and accurately recorded people’s key needs, to ensure smooth transitions to other services when needed.

The provider had implemented robust processes to accurately record information from other professionals including when people attended other healthcare settings. This information was then relayed to staff consistently and implemented into people’s support plans.

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 provider, new registered manager and staff team had worked hard to ensure people were safe and protected from the risk of avoidable harm. Risks to people were robustly reviewed, new processes were in place, and staff and people were regularly encouraged to speak up openly and honestly if they had any concerns. The registered manager had an open-door policy and encouraged open dialogue to support the safety of everyone using the service and continuous improvement.

Staff had received safeguarding training and spoke confidently about what safeguarding meant and their role and responsibilities. One staff member told us, “It is our duty to make sure people are safe. If I had any concerns, I would immediately inform my manager. I currently have no safeguarding concerns.” A healthcare professional who worked with the service confirmed that, “All safeguarding issues have now been resolved.”

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 the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The registered manager had robustly reviewed and updated people’s support plans and risk assessments. This had been done with input from relevant healthcare professionals, family members and people themselves. This meant that support plans now reflected people’s needs and wishes, including how people wanted to manage risks.

Risk assessments were completed regularly. Recognised best practice tools were used to assist these assessments. There was clear and detailed information available for staff about people’s specific health needs, including risks associated with those needs, things for staff to be aware of, and actions for staff to take in different situations.

The registered manager had pro-actively liaised with healthcare professionals to ensure that guidance for staff was correct and contained accurate and appropriate information. As a result, staff had clear and consistent guidance to follow to enable them to manage risk positively. This had notably improved the quality of care people received.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had renovated areas of the service, including installing a new kitchen for people to use. Maintenance had improved and the home was a safe and pleasant environment. Work was ongoing in the outside area, with plans underway to create a sensory garden for people to enjoy.

People had personal emergency evacuation plans in place, to assist staff and the fire service in the event of a fire. These accurately reflected people’s evacuation needs. The provider had completed mock evacuation drills and identified this was an area for improvement. Further drills were needed to improve the evacuation process. The provider confirmed further drills would be completed imminently and staff had completed additional training in this area.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were recruited safely, with appropriate pre-employment checks carried out. There were sufficient numbers of staff on shift, and further recruitment was ongoing. Staff comments included, “The houseis currently fully staffed, and it has helped us to deliver quality care to people, I don'thave to rush my tasks because we are fully staffed.”

Staff had received additional training following our last assessment, in areas such as safeguarding, first aid and providing person-centred care. Staff received regular supervisions to support them in their role, and told us, “I find supervision sessions very useful to me as they give me the chance to reflect on my work, talk about any challenges, and get guidance”, and “I am happy with the level of support and training I receive.”

The provider assessed and managed the risk of infection.

Processes were in place to support good infection prevention and control. Staff had ample access to PPE, including gloves, masks and aprons. Handwash and paper towels were readily available throughout the service. Clinical waste was disposed of appropriately, and the outside bins had been appropriately stored and secured.

The house was kept clean and tidy. One relative told us, “The house is clean and in good order, I have no concerns in this area.”

Medicines were managed safely, and people received their medicines as prescribed. People’s medicines were stored securely and kept at the correct temperature. Medicine administration records were clear, accurate and consistently completed. Where people were prescribed medicines to be taken on a ‘when required’ basis, there was clear guidance for staff as to when those medicines should be administered. The registered manager had sought clarification from GPs and pharmacists around the correct administration of creams and lotions, and this information was clearly recorded in people’s support plans and medicine records. Where medicines were time critical, staff recorded the time of administration.