Homebeech

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 remained 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 provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 did not always have a proactive and positive culture of safety, based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events, for example, in relation to risks as a result of building works. Lessons were not always learnt to continually identify and embed good practice. This was evident based on the history of the home with regard to continued lack of compliance with regulatory requirements.

A staff member explained if an incident occurred, a form would be completed, the nursing team would be alerted and information shared with other staff. The manager said if a medication incident occurred, a ‘medication reflection’ would be completed with the staff member involved, the surgery would be informed [or out of hours team], and whether there were any adverse effects for the person receiving the medicine.

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 services.

Information about people’s care and support needs was shared with other care providers and professionals when required. If it was felt a person’s care and support could no longer be provided at Homebeech, a meeting amongst the senior team would take place.

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 understood people’s rights in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards legislation. Staff had completed training in these areas.

People told us they felt safe living at Homebeech. One person said, “We seem to do all right.” Another person told us, “Very much so. If there’s anything I wanted, I would ask and it would be supplied. I feel at home here.” Staff completed safeguarding training and were knowledgeable about the signs and triggers that might indicate abuse. The manager completed notifications of abuse or alleged abuse to the Commission in line with regulatory requirements.

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 understood people’s rights in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards legislation. Staff had completed training in these areas.

People told us they felt safe living at Homebeech. One person said, “We seem to do all right.” Another person told us, “Very much so. If there’s anything I wanted, I would ask and it would be supplied. I feel at home here.” Staff completed safeguarding training and were knowledgeable about the signs and triggers that might indicate abuse. The manager completed notifications of abuse or alleged abuse to the Commission in line with regulatory requirements.

The provider did not always detect and control potential risks in the care environment.

At the last assessment it was observed the home had been poorly maintained. At this assessment, progress had been made in the redevelopment and redecoration. New flooring was clean and well maintained, and we observed cleaning taking place in communal areas. However, a vacant room between rooms 23 and 24 was left unlocked; the flooring was exposed down to bare boards and there was a hole in the flooring with exposed pipes which could have caused injury. In addition, the light fitting was loose with exposed wiring which could be hazardous. A door to the roof on the top floor had been left unlocked and people could have accessed this area which was unsafe. A chair had been left out there which people could have used to climb on with the risk of a serious fall from height.

We discussed our concerns with the manager. They informed us the contractors employed in building works would be reminded of the need to keep areas secure when left unattended.

The provider did not always make sure there were enough qualified, skilled and experienced staff to ensure people’s support needs were met in a timely manner or that met their individual needs.

People provided mixed feedback when we asked whether they felt there were enough staff on duty. One person said, “It can be ragged. Some people get more service than others, but they do their best. When there’s so many people and not enough staff, what can you do?” Another person told us, “There’s loads of staff, but you still have to wait half an hour or an hour sometimes. That’s night-time as well; they could do better there.”

The home was reliant on a high use of agency staff due to problems with recruitment, although the same agency staff consistently worked at Homebeech. For example, at our site visit there were 14 care staff on duty of which 9 were agency. A permanent staff member said, “I don’t think there is enough staff. There’s a lot of people with hoisting needs.” The staff member added it was difficult to respond to call bells promptly sometimes, and said, “I’d like to spend more time with the residents, but you can’t do that here. You’ve just finished something and then someone calls you to do something else; it’s just constant.”

We observed ambulance crew were left waiting in a corridor as they waited for staff to assist them when 1 person was returning to the home from hospital when they were still unwell.

Staff completed a range of training to enable them to undertake their role and responsibilities effectively with regard to everyone living at the home. This included Oliver McGowan training which is the recommended training. The Health and Care Act 2022 introduced a statutory requirement that CQC registered providers must ensure their staff receive learning disability and autism training appropriate to their role. Staff were knowledgeable about this training. Staff received regular supervisions.

Recruitment systems were effective and appropriate checks were made to ensure new staff were safe and suitably qualified to work in a care setting.

At the last assessment some areas were found to be unclean, for example in bath and shower rooms, with loose taps and fittings also a concern. Work had been completed to improve the bathing facilities, with a new wet room.

Whilst improvements had been made, we found other areas of concern. For example, we saw wet or soiled, unbagged incontinence products had been left on 1 person’s bathroom floor for at least 3 hours. As the door to the toilet was left open, the smell was evident from the corridor. We observed a staff member moving soiled laundry in a red bag without wearing disposable gloves increasing the risk of cross infection. Some of the upholstered chairs in people’s bedrooms were visibly soiled, along with a footstool in a small lounge being dirty This did not create a clean and dignified environment in which to live.

People gave us mixed feedback when asked about the cleanliness of the home. One person said, “It’s clean, they wash the floors.” Another person told us, “The cleaners need training too; they don’t do a room properly. They don’t clean my bedroom properly.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes occurred.

We observed a registered nurse giving people their lunchtime medicines. One person wore a continuous glucose monitor under a patch which measured their blood glucose levels. The nurse checked the reading and administered the amount of insulin injection according to the result of the reading. Another person appeared not to know the nurse on duty, so they reassured them, explained who they were in a kind and gentle manner, before giving them their medicine. All aspects of medicines were managed safely, including ordering, storing, and disposal of medicines. Staff completed medicines training and their competency to administer medicines was assessed.