Oxford Beaumont

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 remained good. This meant people were safe and protected from avoidable harm.
 

This service scored 72 (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.

Systems were in place to ensure safety incidents and concerns were reported, investigated and reviewed appropriately. Staff told us they completed forms following incidents, which were then reviewed and any required actions for people’s safety completed. A relative confirmed staff were good at keeping them informed of any issues. A staff member explained the learning from a recent safety incident review and how key points were shared with staff through clinical risk and staff meetings. The provider also shared learning outcomes across their other homes.

The provider had processes to monitor, identify and act upon any trends in incidents, such as an increase in the number of falls or wounds people experienced. Staff were also updated regarding any national safety alerts to enable them to take any required actions to support people safely.
 

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.

Staff told us, “Handovers provide all the information for a newly admitted person.” People’s care records also informed staff about their care needs and any associated risks when they moved in, which ensured people’s needs could be met. One person told us, “Everything was ready for me, and the staff already knew exactly what I needed,” highlighting the provider’s proactive approach to planning and communication.

People and their relatives told us they were fully involved in the initial assessment process. One relative said, “The assessment was thorough. They [the provider] visited [the person] in the community hospital, spoke with [them], me, and the staff at the hospital.”

The provider had processes to ensure relevant information was shared with other services and professionals when people were transferred to external services, such as hospitals. The electronic care planning system enabled staff to produce a ‘hospital pack’ for the person, which contained relevant information to support the person’s safe transfer.

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 completed safeguarding training both as part of their induction and through regular refreshers. Staff spoken with understood what abuse was, what to report and to whom. The provider ensured relevant authorities were notified of any concerns which were then investigated. People’s records confirmed both they and their families participated in safeguarding decisions. Records showed staff had spoken with a person’s family about how to keep them and others safe in a way which did not restrict their human rights.

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 where people were subject to restrictions for their safety, their consent was sought. If they lacked capacity to consent, an MCA assessment was completed and a best interest decision made which involved relevant parties. The provider submitted DoLS applications where required for people and the status of their application and any associated conditions was recorded to inform staff.

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.

People’s care plans demonstrated risks to them had been assessed and strategies were in place to enable staff to provide them with safe care. A person’s care plan described signs of when they were becoming distressed and the actions staff should to take to maintain safety, which reflected what their relative had told us.

Records showed people were consulted where possible about how they wanted risks to them managed. The registered manager said, "[Person] is encouraged to be as independent as possible, but [person] has a strong risk of getting disorientated, but we [staff] do try to strike a balance." The registered manager had completed a comprehensive, collaborative risk-assessment to implement freedom of movement in the least restrictive way using discreet staff monitoring. Staff spoke confidently about how they balance keeping people safe without restricting their personal freedom and human rights when making decisions around risk.

We saw multiple examples where staff supported people to take positive risks, including enabling people to access the community independently, manage aspects of their own health conditions, and maintain important routines. Outcomes were consistently positive, with people experiencing improved confidence, reduced anxiety and greater control over their lives.

People’s risks were reviewed regularly, and staff were updated through meetings, handovers and the person’s records, about any changes made and the ongoing management of risk. People’s clinical risks were kept under review at the provider’s clinical risk meetings.
 

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 ensured required safety checks were completed, and safety certificates were in place for electrical, gas, water and fire safety. There was evidence equipment had been maintained and regularly serviced. Staff said, “I am most aware of risks such as slips, trips, and falls, infection control risks and hazards related to cleaning chemicals. To manage slips and trips, I make sure floors are kept clean and dry, any spillages are cleaned immediately. For infection control, I follow strict cleaning schedules, using correct Personal Protective Equipment (PPE), hand washing, ensuring colour-coded cleaning systems are followed, separate bins are provided for waste management. With cleaning chemicals, I will make sure it is stored correctly, never left unattended.” The building was secure and safe, hazardous substances were stored securely.

The provider ensured health and safety audits were completed in order to identify and address any safety issues. Processes were in place to enable staff to report any concerns with the environment which were then addressed. The management team took active roles in daily ‘walk abouts’ covering both the internal and external premises for clear oversight.

We observed aspects of the service required modernising; this was noted on the provider’s service improvement plan and work to address this was underway. Ongoing works included a bathroom instalment, replacement flooring in a sluice, and outdoor refurbishments to ensure the environment remained safe, accessible and suitable in all weather conditions.
 

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.

The provider had processes to assess people’s needs and to calculate staffing requirements. We saw there were sufficient numbers of staff deployed to meet people’s needs and to maintain their safety. People, relatives and staff confirmed there were enough staff to support people. Their feedback included, “Enough staff, they are always busy and working hard,” and “There is definitely enough staff… they all know us here.” Staff also confirmed this, with one stating, “There is enough staff on duty to meet people’s needs.”

Staff had an induction to their role, training and regular one to one meetings. Nurses completed clinical trainings to update their knowledge and meet their professional registration requirements. One staff member told us, “The induction I received was very helpful and in depth.” Staff supported people in a way which showed they were well trained.

The service benefitted from a stable and experienced staff team, with many staff having worked at the home for a number of years. This supported the delivery of consistent, personalised care from staff who knew people well.

We saw staff responded positively and competently when people showed signs of emotional distress. People spoke positively regarding a good staff presence, one person noting there was “always someone around.” Observations throughout the inspection supported this. Staff were visible, responsive and had time to interact positively with people.

Overall, there were safe recruitment practices. Pre-employment checks were carried out to ensure the appropriate vetting of staff.
 

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.

We found the service to be clean, tidy and well maintained. Domestic staff were observed carrying out their duties effectively. Hand sanitiser was available throughout the home, and signage promoted good hand hygiene practices.

Staff completed infection control training and followed best practice guidance. Staff were observed to be using appropriate personal protective equipment (PPE) whilst carrying out their duties.

People and their relatives told us the home was clean, which we observed. The providers cleaning schedules for the home were completed consistently by staff. Staff spoke confidently about infection control practices. One staff member told us, “I always follow infection control procedures, use PPE and ensure good hand hygiene.” Another said, “Good hand hygiene is very important… before and after personal care.”

At the time of the inspection, one sluice was temporarily out of order due to refurbishment works. The provider had implemented appropriate contingency arrangements to ensure infection prevention and control standards were maintained. Staff were aware of these arrangements and confirmed they were effective. We saw no impact on the cleanliness of the environment or staff practice.
 

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

People’s medicines records showed they didn’t always receive their medicines safely and as prescribed however, staff were knowledgeable about people and their medicines, and people's preferences were taken into account.

There were suitable arrangements for ordering, storage and disposal, including for medicines needing cold storage and those requiring extra security. Suitable temperature monitoring was carried out to make sure medicines were safe and effective however auditing did not always effectively pick up issues. For example, we found some concerns with medicines that the provider had not identified prior to our inspection these were low risk and addressed promptly. On one occasion, a staff member signed the MAR before confirming administration; effective strategies were implemented, including additional competency checks and reflective practice to reduce the risk of reoccurrence. A small number of expired medicines were found in storage which had not been identified in the most recent audit; these were unopened, not in use, and removed immediately with no impact on people. There was also a discrepancy between a pharmacy label and MAR instructions for one medicine; however, staff were administering it correctly in line with current prescribing guidance. Records were quickly updated to ensure consistency and reduce future risk. Overall, the provider responded effectively to issues and used them as learning opportunities.

People’s records contained detailed, person centred information to support the safe administration of medicines. The provider was reviewing people’s constipation medicine plans to provide clear guidance on the effective use of prescribed medicines where dosing was variable or on an ‘as required’ basis, however for 1 out of the 5 MAR charts that were reviewed, we found conflicting information which meant staff could have given the wrong medication dose or at the wrong time due to unclear and conflicting instructions, potentially causing harm.

Records were in place to show risks were considered for people taking higher-risk medicines such as flammable emollients. Staff had suitable, up to date training, and the provider carried out medicines audits routinely to support safe medicines management.