Becket House 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 Good. At this assessment the rating has changed to Requires Improvement. This meant that 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 in breach of a legal regulation in relation to safeguarding people from abuse and the risk of abuse.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

Incidents were not always investigated to understand what had gone wrong and how to reduce future risk. For example, a person sustained an injury and was admitted to hospital. The circumstances were not effectively reviewed so that measures could be put in place to reduce the risk of a similar thing happening again. There was limited analysis of accidents and incidents to help identify if there were any themes or patterns developing.

Staff completed accident and incident forms in a timely manner and people received appropriate medical support.

The service 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. People were supported to see their GP when required. Staff advised that the GP was very supportive. For example, when people required an assessment from the Speech and Language Team (SALT) these were supported by the GP and the appropriate safe pathway of care was met.

The service did not always share concerns about abuse or the risk of abuse quickly or when required. For example, we found a safeguarding referral had not been submitted to the local authority safeguarding team, when there were allegations of abuse. The registered manager acted promptly when this was brought to their attention.

People were at risk of being unlawfully deprived of their liberty due to Deprivation of Liberty Safeguards (DoLS) applications not always being submitted promptly when needed, for example when a person had dementia. We identified a person who was not free to leave Becket House Nursing Home for their own safety, but the legal authorisation was not in place. In response the registered manager completed a referral retrospectively.

Staff received safeguarding training and were aware of the types of abuse and how to report them. People told us that they felt safe and relatives were confident that people were safe at the service.

The service 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’s risk assessments did not always provide information to staff on how to provide support which reduced known risks as far as possible. For example, to include important information such as how and when a person was at greater risk of experiencing falls.

Staff told us they were kept informed of changes to people’s support via the electronic care planning system the service used, however we found some information to be contradictory.

People did not always live in an environment which was safe. For example, some people who were at risk of falls had unnecessary clutter in their rooms which increased the risk of trips and falls. In some bedrooms wardrobes were not securely attached to the walls and there were belongings unsafely stored on top. Some people used bedrails to keep them safe while they were in bed. We found the bedrails were not always used safely, for example bumpers were not always in place or secured safely. These all-increased risks to people’s safety.

Systems were in place to check fire safety. Fire alarms were regularly checked, and fire evacuation tests were undertaken. Equipment in the home, for example hoists and wheelchairs, were tested in line with current guidance to ensure people could safely use them.

The registered manager had risk assessed staffing levels using a dependency tool. The levels of staff on duty reflected the staffing levels risk assessed to meet people’s needs.

We received mixed feedback from staff and relatives regarding staffing levels. A member of staff said that they felt there were not enough staff on at night and another staff member felt there were sufficient staff during both the day and at night. Some relatives said that they would like to see more staff on at weekends.

Staff had received appropriate training to carry out their roles in supporting people at Beckett House Nursing Home. We observed staff were busy and continuously working hard to support people’s needs.

The service did not always assess or manage the risk of infection.

We observed that some people’s bed rail bumpers were old and in need of replacement. One person’s bathroom cabinet was dirty and had rusted. Communal bathrooms were cluttered with commodes, shower chairs and wash bowls which were not always clean.

We fed back to the provider who advised that they would address our concerns.

Staff were observed using appropriate Personal Protective Equipment (PPE) such as disposable aprons when they supported people with their meals.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Topical creams were not always administered as prescribed or dated when opened.

Stock levels of some medicines did not match what was recorded on people’s Medicines Administration Record (MAR). There was no evidence these discrepancies had been identified or investigated. These findings increased the risk of people not correctly receiving the medicines they were prescribed. Protocols for medicines which were administered ‘when required’ (PRN) did not always give clear guidance to staff.

For example, what signs to observe when a person was unable to say when they were in discomfort or pain.

The registered manager responded swiftly when these concerns were brought to their attention, they carried out a medicines audit, implemented daily medicines checks and booked more training for staff.