Belsfield 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 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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and their relatives felt accidents and incidents were managed well. Relatives told us staff supported people with their mobility to minimise the risk of falls. Staff knew what to do should someone have a fall. One staff member said, “If a fall occurs, staff press the emergency buzzer and senior (staff) and nurses come to assist.” Partners told us they were kept updated about recent safety events.

Accidents and incidents were managed well and there was not a high number of falls occurring. Infrared cameras were consented to and fitted in some bedrooms which protected people’s privacy but also provided an overview of how a fall may have occurred. This helped to minimise future risks. A ‘traffic light system’ was used to guide staff on the process should an incident occur, and accidents and incidents were analysed to identify trends and themes.

The service 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.

Relatives were positive about the admission process into Belsfield House. One relative said, “When [person] moved from home to home (the service) they (management team) sent a member of staff with to help him settle in, but he soon settled in, faster than we thought.” Other relatives spoke of how quickly their loved one settled into the service and how easy the process was. Staff told us about the process for when a new person comes to the service. This included initial assessments, involving family members to help get to know the persons needs and wishes.

The registered manager told us people were moved between services safely and that a full handover would be provided as well as direct communication with the new service to support continuity of care. Processes were in place for when people were taken to hospital in emergency situations. This included taking important records such as DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) forms, medical information and any personal items. Detailed hospital passports were in place. Partners told us hospital admissions were handled without any issues.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People and their relatives felt safe using this service and relatives told us of situations in the past where they had concerns that were immediately rectified. One relative said, “(I have) no concerns, if there is even a little mark on [person] they (staff) will tell me even if I wouldn’t see it, every change they make they let me know. When they ring me, they start by saying, there is nothing to worry about and they ask me if I am happy with what they are doing.”

Staff overall could tell us how safeguarding concerns were managed. One staff member said, “We have had safeguarding training, and we can spot signs of abuse, anyone can raise a safeguarding and should do if they have concerns. We report concerns to the nurse first.” We observed staff presence throughout our inspection and for anyone who required 1-1 staff, there was always a staff member there. People were observed to be protected from the risk of abuse and harm.

Systems were in place to investigate and learn from safeguarding concerns including outcomes and lessons learnt processes. A detailed safeguarding policy was in place, and we saw evidence of information sharing and best interest meetings taking place to discuss safeguarding concerns and what measures will be implemented to help reduce future risks. A DoLS (Deprivation of Liberty Safeguards) tracker was in place, and we saw evidence of DoLS applications being followed up as appropriate. Staff had good knowledge of DoLS, and we saw focus was put on any conditions people may have as part of their DoLS. These conditions were shared during weekly updates and handovers to ensure these conditions were met.

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

Relatives praised staff on how they managed distressed behaviours. One relative said, “They (staff) deal with [person] calmly. There are a couple of members of staff who come when [person] is (distressed) and they can turn them around. They are very caring; they are remarkable people. The staff never know what they are going to get, and they are able to deal with it.” Staff told us how they help to reduce periods of distress. One staff member said, “1-1’s change every 2 hours so people don’t get agitated or bored seeing the same faces.” The registered manager spoke of positive risk taking. This was promoted by enabling choice and autonomy while managing potential harm. The registered manager said, “Staff have gone simply beyond managing risk, they have created a safe, structured and compassionate environment.”

We observed staff to be patient and calm. We noticed staff walking with people to minimise the risk of falls and we witnessed an incident whereby a person became distressed, and staff managed this calmy and professionally while ensuring people and staff safety. Risk assessments were in place. However, more work was needed around risk assessments for specific health conditions such as diabetes to make them more person-centred. Information was available on what may cause a person to become distressed and distraction techniques for staff to use including meaningful communication to avoid any escalation. There was also a section for safety interventions and personal care tips for least restrictive approaches.

The service did not always detect and control potential risks in the care environment. We observed some safety concerns including, unlocked cupboards containing cleaning products and chemical spray bottles which were left within people’s reach during our site visits. Powder used to thicken drinks was stored in an unlocked box in an open room. This could pose as a choking risk to people. These concerns were rectified immediately.

People and their relatives told us the environment people lived in was safe and free from hazards. One relative said, “It is almost like a hospital in that it is shipshape, [person] has a bell in her room and if we ring it, they (staff) come running, they are personable but have a completely professional outlook on it.” Staff knew what to do should a fire occur, and fire drills were taking place monthly.

We did observe other parts of the service to be safe including locked, secure units, window restrictors and secured wardrobes. We saw evidence of checks being made to the environment including water temperature checks, portable appliance testing and checks on moving and handling equipment. Fire checks were in place including fire alarm checks, fire doors and emergency lighting checks. PEEPS (Personal Emergency Evacuation Plans) were recorded in people’s care records as well as a paper file. This included how much support a person needed should a fire occur and how to safely evacuate a person.

The service made sure there were qualified, skilled and experienced staff. Staff had completed training relevant to their role.

Staff recruitment processes were robust, and relevant checks were in place. We did however find the service was not always working in line with their own recruitment policy. The registered manager took this feedback on board and is looking to update the policy. DBS (Disclosure and Barring Service) checks were in place as well as interview checklists. Staff undertook a thorough induction when they commenced their role. One staff member praised the induction period and advised they were shown around the service and told the fire procedures. Staff then went onto shadow other members of staff until they felt confident in their role. The rota and our observations evidenced there was enough staff. One staff member said, “There is always enough staff, everyone who needs 1-1 (has one). Sometimes there are occasional slips with staff, but additional training and support rectifies this. There is always enough time to spend with people and there are plenty of training courses.”

Relatives praised the staff. Their comments included, “You cannot fault the home, I have never seen so many staff” and, “I think it’s very well staffed, anyone who comes in comments on the number of staff around, I think there’s more staff than is mandatory, they have 3 qualified nurses.” Staff were receiving regular supervision in line with the service’s policy.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Relatives praised the cleanliness of the service. One relative said, “Yes, it is very clean, very clean with no smells. The cleaners (housekeeping) seem to go around the floor every 3 hours. One day a picture fell off the wall and the next day it was back up. There is no smell around the toilet or bathrooms.” Relatives told us staff wore PPE (Personal Protective Equipment) as appropriate and felt outbreaks had been managed well in the past.

Staff told us the service was clean and that there were plentiful supplies of PPE. We observed the environment to be clean and tidy with no malodours. Environmental checklists were in place and IPC audits were being carried out. There was an IPC champion who took the lead in this area and was a point of contact for staff should they have any concerns. We did however find some concerns in the kitchen area including freezers that required defrosting, food items stored on the floor and personal items belonging to staff in the kitchen store. We also found the laundry room was full of laundry bags stored on the floor. This was rectified during our site visit.

The service made sure that medicines were administered to safely meet people’s individual needs. People were appropriately involved in decisions about their medicines.

Care home staff worked with other professionals to review people’s medicines needs. People were supported to take their medicines when away from the service, if needed. However, although kept under review, these arrangements had not been recorded for one person. We raised this with the registered manager so this could be promptly addressed. Arrangements were in place should the covert (hidden) administration of medicines be needed. Care plans included information to support the safe administration of medicines.

Records we checked showed people were having their regular medicines administered safely. Staff members had received training in the safe administration of medicines and were assessed as competent before supporting people. Regular medicines audits were carried out so that should any shortfalls be identified, they could be promptly addressed. We found a record keeping error in the controlled drugs register. Controlled drug record keeping had recently been identified as an area for improvement by the registered manager and steps were being taken to bring about improvement. Medicines including controlled drugs were safely stored.