Beechwood 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the way people’s medicines were managed.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff did not always record or raise incidents appropriately. Staff recorded some significant incidents in daily notes and behaviour charts, but these were not escalated or logged formally as incidents. The management team had limited oversight of daily notes and behaviour charts. This led to some of the incidents not being managed appropriately.

Where staff did record incidents appropriately, they were not always investigated robustly, and there was limited evidence of learning from some incidents. This meant some types of incidents kept recurring, which resulted in people suffering harm, and being exposed to risk of harm.

The provider had completed an incident analysis covering a 3-month period. This analysis did not consider incidents which had been recorded in daily notes and behaviour charts, but which had not been appropriately flagged by staff as a formal incident. The provider was unable to locate any earlier incident analyses. There was no evidence of weekly or monthly analyses, which would have helped to identify trends, themes and concerns at an earlier stage. We were not assured that incidents were managed appropriately to ensure continuous learning and improvement.

The provider generally worked well with people and healthcare partners. They made sure there was continuity of care, including when people moved between different services.

Referrals to healthcare partners were made appropriately, including to services such as the falls team and the dietician. Relatives told us, “They are quite sharp about getting the doctor” and “[Relative] has seen the dietician and now has extra yoghurts and mousses.” Advice from healthcare partners was incorporated into people’s care plans. Care plans were up-to-date and contained person-centred information, which supported people’s safe transitions and access to other services.

The provider did not work well with people to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were not safe in their own home. The provider did not control risks and did not put effective safeguarding measures in place. This failure exposed everyone using the service to harm and the risk of harm. There were multiple incidents where people suffered physical injuries, such as wounds, and psychological harm, including distress and anxiety. One relative told us, “Residents have the right to be safe and secure in their own space, and some residents do cause others anguish.”

Some people expressed themselves through verbal and physical aggression, which increased the risk to others. Staff did not have the tools or support they needed to keep people safe. One staff member said, “I am concerned. The service is not safe for other residents. I do think people are at risk. A door sensor might go off but by the time we get there something might have happened.”

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 DoLS were in place and had been applied for appropriately. The provider clearly recorded any conditions contained within DoLS and had oversight to ensure timely applications for renewal when needed.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not manage risks from people who displayed verbal and physical aggression. As a result, people experienced repeated physical and psychological harm and remained at risk of further harm. Control measures were weak and rarely reviewed, so staff could not judge whether they worked. The manager and the provider did not understand the seriousness of these risks and did not take timely, effective action or learn from previous incidents.

People’s hydration needs were also poorly managed. One person went long periods without fluids. Fluid records for some people showed intake far below recommended levels, yet no action was taken. Relatives told us, “[Person’s] jug is usually away from the bed with a glass which is often full and [person] can't reach”; “Quite often I come in and [person’s] jug of fluids is tucked in behind the television out of reach”; and “I've gone when [person] has been clearly thirsty on a number of occasions.”

After receiving feedback, the manager in post at the start of the assessment introduced measures to improve monitoring of people’s fluid intake. By day 2 of the assessment, a wider range of drinks was available, staff encouraged people to drink, and they supported people who needed help.

People’s care plans generally contained a good level of detail and person-centred information around areas of risk, such as medical conditions, mobility and nutrition. Recognised risk assessment tools were completed for people on a regular basis.

The provider did not detect and control potential risks in the care environment. On day 1 of our assessment, we found prescription thickener stored in communal areas unlocked and accessible to people. This posed a significant safety risk if someone were to ingest this. Despite feeding back our concerns, prescription thickener was accessible again on day 2 of the assessment. Prescription creams were also accessible to people using the service who may not have understood the risks posed by those creams.

The provider had not created an environment which ensured people were protected from physical and psychological harm. The use of equipment within the environment, such as door sensors, had failed to ensure a safe environment for people.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Whilst there were generally enough staff on duty, there had been a high use of agency staff at the service. On day 1 of our assessment, we identified a serious concern in relation to the conduct of 1 agency staff member. The provider took immediate action. Following our feedback, the provider introduced additional checks and observations for agency staff members to ensure they worked in line with the provider’s values.

Not all nurse training was up to date, although at the time of the assessment the service did not support anyone who would be impacted by the omissions in training and contingency measures were in place.

Staff received supervisions and appraisals but told us recently these had left them feeling demoralised due to a lack of recognition of their hard work. One staff member told us, “We don’t get a thank you or any praise.”

The provider’s recruitment procedures were robust and all appropriate pre-employment checks were completed.

The provider did not always robustly manage infection prevention and control. Whilst cleaning schedules were in place which included deep cleans and the cleaning of equipment, some areas of the service required additional cleaning such as glass panes and flooring. These issues were generally resolved on day 2 of the assessment.

Soiled laundry was not always dealt with appropriately. There were areas of chipped paintwork and woodwork which meant those areas could not be effectively cleaned.

Relatives and people mostly provided positive feedback about the cleanliness of the service. Comments included “The bedroom and dining room are always clean. No issues there and I see people cleaning”, “There is always someone cleaning; the home is a lot cleaner now” and “The room and bed are always clean and tidy. The corridors smelt nicer this recent visit, and general areas look tidy with no clutter lying around."

The provider did not make sure that medicines were managed safely.

Medicines were not always stored appropriately. The medicines fridge was outside the recommended temperature range and had consistently been so for approximately 5 months. There was no documentation to show staff had escalated this, which meant medicines were at risk of being kept in unsuitable conditions and unsafe to use.

People that were prescribed ‘as and when required’ medicines had protocols in place. Some of these protocols contained incorrect doses in the instructions for staff, which could lead to incorrect administrations. Where people were prescribed variable dose medicines, guidance was not always in place for staff to know how much to administer and when.

One person had been exposed to the risk of harm as they had gone a significant period of time without a critical medicine. Laxatives were not always administered when required.

Some out-of-date liquid medicines had been administered, and this had not been identified by the manager in place at the time of the assessment, despite an audit being carried out.

Time-critical medicines were not always administered with the appropriate time gap in between doses. This placed people at risk of overdose.

When people were prescribed multiple creams, staff did not clearly document which cream was applied to each area of the body, making it difficult to confirm whether people received their creams as frequently as prescribed. Body maps were not present to show where staff had applied these creams.