Beckoning House Limited

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. This is the first assessment for this service. This key question has been rated 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 regulations in relation to safe care and treatment and to fit and proper persons employed. The registered manager had not completed the appropriate checks to ensure that staff were recruited safely into the service. Staff did not always assess risks to a person’s health and safety or mitigate them where identified. Risk assessments were incomplete and did not include risks we identified during our assessment. The person using the service did not always have a detailed, accurate and up to date care plan to guide safe practice.

This service scored 53 (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 always have a proactive and positive culture of safety based on

openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The registered manager shared knowledge and information with staff during supervisions and meetings and records confirmed this. However, there were no action plans completed to evidence how issues raised were to be addressed, dates to be achieved, if actions had been resolved, remained outstanding or whether there was a formal record of lessons learnt. A member of staff told us, “The manager keeps us up to date with any changes to the persons care package.” This limited the ability to learn from incidents and feedback, meant learning from good practice was not always identified or embedded across the service.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

The registered manager told us, “A meeting takes place to carry out a full assessment before we commence a support package to determine if we are able to support the individual or not. We also look at what additional training our staff may need to ensure the person receives the best support.” Staff told us they read through the care plans to ensure they had all the information they needed to provide support safely. A relative told us, “We had a meeting with the manager before the package started, and they asked us all the necessary questions.”

However, the completed initial assessment and care plan lacked detailed and did not contain all necessary information required to support a person safely. This meant we were not assured staff had the correct information to deliver support safely.

The service 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.

Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people including informing other agencies if they were concerned about action being taken. A staff member told us, “If I had any concerns about [person], I would escalate them with the registered manager.”

Risks to people's safety and wellbeing were not fully assessed and recorded. Management plans did not provide enough detail as to how identified risks should be managed and mitigated. For example, there was no information available to guide staff on how to support a person with distressed behaviours. This meant that staff may not be able to respond appropriately to changes in the person’s behaviour potentially placing them at risk of harm.

A care plan and risk assessment were not personalised, with the information staff needed to provide support safely. The care plan lacked detail about a person’s specific health and support needs. This meant we could not be assured staff had all information required to manage the risk to the person or to respond to these in a safe and effective way.

People received personal care and support in their own homes. A relatives told us they had seen a completed environmental risk assessment to provide staff with guidance on how to keep the person safe and minimise risks in their own home environment. However, we found limited information in relation to risks to a person’s safety and wellbeing. Risks were not fully assessed, recorded, or provided enough detail as to how identified risks should be managed and mitigated. There were no processes in place to review home environment risks to ensure they remained relevant, reflected people’s current needs, and considered the support in place.

The registered manager had not always ensured staff were safely recruited. We saw gaps in recruitment files, such as staff not having a completed application form containing a full employment history. Staff files held incomplete documentation on staff files in relation to their interview and medical health declaration, and not all references received had been verified or dated correctly. There was no evidence the registered manager carried out a regular staff file audit. This meant the registered manager could not be assured that staff were suitably skilled, qualified and safely recruited to meet people’s needs.

Staff were subject to Disclosure and Barings checks (DBS) when they first applied to work at the service. These checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff told us they were supported with an induction and given the opportunity to shadow more experienced staff when they first started working. However, the induction on file comprised of 1 day, did not include shadowing shifts and did not demonstrate a robust induction had been completed to enable staff to carry out their role and responsibilities effectively.

The service currently supported 1 person and had enough staff to provide this support. The registered manager told us they would recruit more staff as they took on more care packages. The provider was unable to demonstrate that recruitment practices consistently safeguarded people or ensured staff were suitably qualified to deliver safe, effective care.

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. Staff had undertaken infection prevention and control training and were provided with personal protective equipment (PPE) which could be collected from the office. A member of staff told us, “I wear PPE when required, such as gloves and aprons during personal care and masks if needed.” A relative told us, “The staff member always wears PPE.”

We could not collect the evidence to score this evidence category. At the time of our inspection no one required staff to support them with their medicines. The registered manager told us, when required, regular audits of medicines documentation and practical observations of staff competency will be carried out to ensure safe administration and support of medicines.