Beaconville Nursing 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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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. Lessons were not always learnt to continually identify and embed good practice.

The service had some systems to learn from safety events, but these were not always robust. Incident and accident records were maintained and analysed, yet a falls analysis report missed recording one fall, indicating gaps in oversight. We saw incidents had been analysed, lessons learnt were identified and shared to improve the quality for the people living at the service.

Staff understood the importance of reporting concerns and safeguarding issues, and notifications to CQC were made when required. Staff told us the management team keep them updated and shared lessons learnt in relation to safeguarding concerns.

A relative told us, “There have been a few incidents over time, (Person’s name) has fallen a couple of times, they deal with incidents promptly, and very well. They call me, explain why it happened, and steps taken to prevent it happening again. I could see the incident report which clearly told me everything I needed to know to feel reassured that (Person’s Name) is safe.”

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 different services.

The registered manager had a strong awareness of the risks to people across their care journeys. Their approach to identifying and managing these risks was proactive.

Processes were in place to support safe transitions and continuity of care. Hospital passports and treatment escalation plans were available, and staff provided welcome packs for people moving to the service.

Relatives told us they were listened to, and their views were considered.

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, and avoidable harm and neglect.

People told us they felt safe at the service.

The provider shared concerns quickly and appropriately with healthcare partners. Staff demonstrated a clear understanding of safeguarding responsibilities and acted appropriately when concerns arose. The registered manager raised and escalated safeguarding issues, and notifications were submitted as required.

A DoLS tracker was in place, supporting compliance with legal safeguards. 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 DoLS applications had been applied for appropriately and in line with the Mental Capacity Act 2005. While safeguarding practice was generally effective, recording of communication dates with external teams could be improved to strengthen audit trails.

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

Risk assessments were used to identify hazards and were generally comprehensive, they were person-centred and regularly reviewed. Staff engaged with individuals and families, although feedback from relatives about their involvement with risk assessments was mixed.

Staff told us they could rely on the electronic care planning system for up-to-date information and they had time to read and understand the information in relation to risk management to ensure risks were mitigated.

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

Environmental safety needed further improvement. Fire safety checks and drills were completed, and COSHH (Control of Substances Hazardous to Health) controls were in place. However, a large hole in a bathroom ceiling posed a fire risk, and the Legionella risk assessment was overdue, which potentially put people at risk of harm. Some areas of the home remained poorly decorated. These issues indicated that while some measures were effective, the environment was not consistently maintained to a safe standard, however we found people had not come to harm. We discussed this with the registered manager, who had contacted the provider to address these concerns.

Portable heaters in the building had not been assessed, for risks associated with people being burnt. However, we raised this with the registered manager who took action to address the risk straight away.

A relative told us, “There has been a lot of work in the home in the past 12 months, which has improved the environment massively.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing arrangements were mostly safe and effective. Supervisions and competency checks were completed, and training compliance was high, with the registered manager addressing gaps with staff. The provider was working to ensure 24/7 nurse cover, when this was not achieved the registered manager had a robust process and risk assessment to minimise any impact on people’s safety.

Safe recruitment practices were being followed. Staff had references, and Disclosure and Barring Service (DBS) checks, as required. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Nurses working within the service had valid and up to date PINs. PIN checks show who can legally practise as a nurse or midwife in the UK.

Most staff told us they enjoyed working at the service and were positive about the improvements made over the last 12 months. Comments included, “It has massively improved and in terms of the leadership and all the decoration and the environment,” and “(Management team names) look after everyone, all staff and residents, it is really nice and they have a good balance. They make sure all care needs are met, but they also look after the staff as well, they give people opportunity to grow.”

We observed staff being kind and caring towards people living at the service. Staff anticipated people’s needs, and supported individuals who were distressed, using techniques to provide reassurance.

Relatives were positive about staff. Comments included, “Relationship is very good with the senior staff on the floor, I do know everybody,” and “The staff are doing the very best that they can, which makes me happy.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Relatives told us the service was clean and tidy. The home appeared clean and tidy, and cleaning records were maintained. Staff were proud of improvements, such as a newly decorated COSHH (Control of Substances Hazardous to Health) room.

Most staff had completed training for Infection Prevention and Control (IPC), and personal protective equipment (PPE) was available and used appropriately. One staff member told us, “We have the PPE available, and we have the stations, such as handwashing. We have yellow bins and we have gloves and aprons for personal care”.

The registered manager knew where to obtain information regarding relevant guidance, such as outbreak management, and who to escalate concerns to, for example, Public Health and people’s GPs, where required. Professionals confirmed concerns were escalated and managed appropriately.

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

Medicines were generally managed well, with audits completed monthly and actions taken. Since the last inspection, protocols for medicines taken when required had improved and were person-centred. Covert (taken without the person’s knowledge) medication processes were detailed and followed best practice, including pharmacist and GP involvement. However, the medicines room and cream cupboards were left unlocked during administration, reducing assurance of security and putting people at risk of harm.

Relatives told us people were administered the medication they needed and concerns were escalated. Their comments included, “Medication has been a bit of a concern, more to do with his refusal of it. They escalate this to the GP, we are kept up to date if he declines medication”, and “Medication is managed well.”