Biffins Care 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 regulation in relation to governance at the service.

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. Incidents and accidents were documented and reviewed for themes and trends, and action was taken by staff to minimise risks and keep people safe. Where additional input was needed, support was sought from relevant professionals. Although the service did not use a specific lesson learned form, people’s care plans were updated when lessons were learned, and this information was shared with staff through handovers and team meetings.

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‑admission assessments and gathered detailed information about each person to ensure they received appropriate support. This information was then shared with staff through the person’s care plan.

People were supported to access healthcare services as needed and there were systems in place to share important information in the event of an emergency, for example if a person needed to attend hospital.

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.

People appeared relaxed and comfortable around staff. Interactions between staff and individuals were kind and respectful. Relatives told us they felt their family members were safe and well cared for, and they spoke positively about both the support provided and the staff delivering it. One relative shared, “The care and the staff are lovely.”

Safeguarding systems were in place to safeguard people from abuse. The provider had safeguarding policies and procedures in place, and the registered manager was aware of reporting procedures.

Staff had received training on how to safeguard people. Staff knew how to raise concerns with the registered manager and how to report concerns to external agencies if required. The registered manager encouraged conversations about safeguarding and did this in supervisions with staff regularly.

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 the registered manager understood their responsibility to make DoLS application when required and did this in conjunction with people, relatives and advocates.

The provider worked with people to understand and manage risks by thinking holistically. Risks relating to each person had been identified, and assessments were completed to help them manage these safely. These assessments provided clear and detailed guidance for staff and were relevant to people’s individual needs. People’s communication needs were clearly recorded in their care plans, and staff used this information effectively to communicate with people in ways they understood. This enabled staff to provide support that was responsive to each person’s individual needs. Care plans were routinely reviewed, and although one care plan was overdue at the time of the assessment, this was updated during our visit.

People had access to the equipment they needed to support their safety. However, the use of an alarm sensor mat had not been documented in one person’s care plan, meaning staff did not have a full record of the equipment in place for them.

The service used recognised clinical assessment tools to help manage risks, such as the Waterlow tool to identify people at risk of developing pressure ulcers.

The provider did not always identify or manage potential risks within the care environment. Although there were effective systems for monitoring equipment that required specialist checks, our visit highlighted several areas of the building that were poorly maintained and in need of refurbishment.

The ground floor bathroom was in particularly poor condition, presenting infection control risks and failing to offer a safe, appropriate, or dignified environment for people using the service. These concerns had not been detected through the service’s infection control or health and safety audits. While the provider took immediate action to refurbish the bathroom following our visit, stronger oversight is needed to ensure the environment remains safe and well maintained on an ongoing basis.

People had individual Personal Emergency Evacuation Plans (PEEPs) to guide staff on safely supporting them during an evacuation. Fire safety equipment had been serviced and maintained, and staff had received relevant training, including moving and handling and fire safety.

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

There were robust recruitment practices for the service’s own staff, ensuring they were suitably experienced, competent and safe to work with people before starting their roles. Recruitment checks included full employment histories, suitable references and proof of identity. All staff employed directly by the service had completed Disclosure and Barring Service (DBS) checks prior to commencing employment. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

However, although internal staff had received appropriate checks, the same checks had not been completed for the agency staff supporting one person at the service. The registered manager took prompt action to complete the required checks when this was raised during the assessment.

People experienced continuity of care and were supported by a regular staff team. Agency staff were used only to provide additional one to one support, and the registered manager requested the same agency workers to ensure consistency for the person receiving this support.

Staff felt that staffing levels were appropriate to make sure people received consistently safe care. A relative told us, “The staff are fantastic. They’re ordinary people, down to earth and care so much about my relative and the other residents.”

The provider did not always assess or manage the risk of infection. The provider had systems in place to support infection prevention and control, and staff had received appropriate training and were observed using personal protective equipment correctly. People’s rooms and communal areas were cleaned regularly in line with the service’s cleaning schedules. However, some parts of the environment required improvement to ensure effective infection control. Damaged areas, such as rusted equipment, worn flooring, and deteriorated seals, made thorough cleaning difficult and created avoidable infection‑control risks. Although staff continued to clean these areas to the best of their ability, the environmental issues needed repair to maintain required hygiene standards.

The provider did not make sure that medicines and treatments were safe. Staff responsible for administering medicines had received appropriate training and had their competency assessed. Medicines care plans provided clear guidance for staff, particularly around the support people needed to manage and administer their medicine, however, people’s anticoagulant medicines had not always been assessed in their care plans, this meant staff did not have the specific guidance needed to safely manage the associated risks.

During our visit, we reviewed the medicines stock for two people and identified discrepancies. We also found concerns relating to the management of controlled drugs, including delays in returning them and the presence of expired medicines. These issues indicated that existing checks and oversight were not sufficiently robust to ensure safe practice.

At the time of the assessment, the service did not have a comprehensive, in‑house medicines audit process and relied solely on the medication administration system and pharmacy audits. This limited the ability to identify discrepancies and risks promptly. In response to our findings, the registered manager carried out a full audit of all medicines held in the service and introduced a new ongoing audit.