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 inspection we rated this key question inadequate. At this inspection the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

At our last inspection 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.

Whilst some improvements had taken place regarding the way some risks were managed and how some medicines were administered, the service remained in breach of legal regulation in relation to safe care and treatment and the way people’s medicines were managed.

At our last inspection the service was in breach of legal regulation in relation to how people were safeguarded from abuse. Improvements have been made and the service is no longer in breach of this regulation.

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. Lessons were not always learnt to continually identify and embed good practice. Staff did not always recognise concerns about safety.

The interim manager had started to complete an incident analysis each month. This provided a managerial overview of accidents and incidents it did not provide any in-depth analysis of themes and trends. Whilst this had resulted in an initial reduction in accidents and incidents it had not had time to become sustained or embedded.

The provider undertook a quarterly trend analysis. However, this had failed to prevent recurrences. A new monthly analysis meeting had recently commenced. However, this had not had time for the effects to be sustained or embedded. This meant the sharing of any learning was limited. In addition, whilst staff were recording and raising incidents appropriately, they reported confusion about what they should be recording in care plan notes. Concerns identified during the inspection visit had gone unnoticed and unreported by staff.

The provider generally 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.

Systems to monitor and manage safety were in place, but these were not consistently followed or accurately recorded. Although some processes supported continuity of care, including handovers, safety checks and healthcare input, we found inconsistencies in records and gaps in documentation which increased the risk of people not always receiving safe and coordinated care. Staff worked collaboratively with partner organisations and when communicating with relatives. However, this was not consistently supported by accurate or reliable information to ensure safe transitions between services.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety. The provider had shared concerns quickly and appropriately.

People told us they felt safe. Staff identified safeguarding concerns. The interim manager recorded and took action about these and made referrals to the appropriate authorities. However, some safeguards were not always implemented consistently. For example, we observed occasions when one-to-one support was not in place as expected. We discussed this with the interim manager who took action to ensure this was undertaken.

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. However, the provider did not always clearly record any conditions contained within DoLS or have effective oversight to ensure timely applications for renewal were made when needed.

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

People were not consistently involved in managing risks in a way that balanced their safety, independence and choice. While some people and relatives told us they were involved in decisions about care and support, this was not consistently reflected in practice.

Risks associated with people's care and treatment were not always effectively assessed, monitored or managed. Care records and risk management plans contained inconsistencies and were not always kept up to date. Monitoring of areas such as fluid intake, mobility and repositioning was not consistently completed, making it difficult to demonstrate that risks were being effectively managed. Staff did not always recognise or respond promptly to signs that people required support, reassurance or intervention.

These shortfalls increased the risk of avoidable harm. Whilst there was evidence that relatives were becoming more involved in care reviews and discussions about the service, improvements in risk management and oversight were not yet sufficiently embedded to ensure people were consistently protected from risk.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment was not consistently safe. We identified a range of concerns relating to storage practices, maintenance and the general condition of the premises. These included cluttered areas, worn and damaged fixtures, inappropriate storage of equipment and consumables, and concerns relating to fire safety. While some issues were addressed during the inspection, the number and significance of concerns identified indicated that environmental risks had not been consistently recognised, assessed or addressed. People were exposed to increased risks of injury and avoidable harm as a result of these shortfalls.

These findings demonstrated that systems and oversight arrangements had not been effective in ensuring the environment remained safe and fit for purpose. As a result, people could not always be assured they were living in an environment where risks to their health, safety and wellbeing were consistently managed.

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

Staffing arrangements were not consistently effective in ensuring people received safe, responsive care that met their assessed needs. Although staffing levels had been reviewed since the last inspection and recruitment activity was underway, the service remained reliant on agency staff and continued to experience vacancies in key roles. This affected continuity of care and limited the availability of experienced leadership and clinical oversight across the home.

Staff deployment and skill mix were not always sufficient to respond to people's needs in a timely way. However, the interim manager had identified this and had started to make changes.

Staff knowledge of some people's individual needs and risks was inconsistent, resulting in variation in the quality of support people received.

These shortfalls impacted people's experiences of care and increased the risk that changes in their wellbeing or support needs would not always be recognised or responded to promptly. While staff worked hard to support people, demands on the workforce meant care was not always delivered in a proactive and person-centred way.

There were signs of improvement. The provider had taken steps to recruit into vacant posts, increase training opportunities and review staffing arrangements. Staff told us morale and support had improved under the interim manager and that positive changes were beginning to be made. One staff member commented, "Staff are doing a good job, they are just stressed and [the provider] needs to bring a more holistic approach." However, these improvements were recent and had not yet resulted in consistently safe and effective staffing arrangements across the service.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control arrangements were not always followed consistently. We found dirty and untidy laundry arrangements, used personal protective equipment (PPE) and wipes left in communal areas, worn surfaces that would not support effective cleaning, and gaps in kitchen cleaning and temperature records. In addition, laundry arrangements had mixed dirty and clean laundry storage, including storing on windowsills. The interim manager had started to introduce cleaning systems and schedules, although these were described as a work in progress.

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

We identified shortfalls in the records and care plans for medicines. Records did not always evidence that an effective system was in place to ensure medicines were safely managed and administered.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Guidance for how these medicines should be administered lacked person-centred information and did not include information on variable dose directions nor did they identify if there was more than one medicine for a health condition. Records did not indicate why medicines had been given and whether they had been effective.

Some people had prescribed creams. There was no guidance for staff to direct them on when to apply these. There were gaps in records used to show creams had been applied. Patch application records were not fully completed to show patches had been rotated in line with manufacturers guidance to prevent side effects.

Medication care plans needed further information or updating when changes occurred. Some contained conflicting information.

Medicines were stored securely including controlled drugs. Temperatures were recorded for the medicine rooms and fridges; however, fridge temperatures had not been recorded daily in line with the providers policy, this had not been picked up in audits.

Comprehensive policies and procedures were in place to support the administration of medicines. Audits by the provider had picked up some of the issues we found, and the providers support manager was working to address some of the issues.

Records of regular medicines followed national guidance including recording people’s allergies. Time specific medicines were administered at the correct time.