Beacon Health Group Limited

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 people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The management team demonstrated an open and transparent approach and were committed to driving continuous improvement within the service. Accidents and incidents were consistently recorded and reviewed to identify themes and trends. When incidents occurred, appropriate action was taken to examine the circumstances, learn from the event, and reduce the likelihood of future risks. Lessons learned were routinely shared with staff through team meetings, communications, and supervision sessions to promote a culture of learning and improvement.

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. People’s needs were assessed before support commenced with involvement of both people and, where appropriate, their families. The provider was in the process of transitioning from paper-based records to a new electronic recording system. The provider recognised the importance of retaining paper records until they were satisfied that all key information had been accurately transferred and was readily accessible to staff through the new system. Records demonstrated the service worked collaboratively with other professionals to support safe and effective transitions between services. One professional commented, “They have often contacted our service, on behalf of their clients, either for advice or giving us information. When asking for our advice, they always follow up.”

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. However, they were not fully aware of the full range of incidents also notifiable to CQC. As a result, some incidents, although managed and reported to safeguarding, had not also been reported to CQC. This was addressed immediately and revised systems for notifications implemented. When people and relatives were asked if they felt safe with support, comments included, “I do, yes I do.”, “Yes I do, very much so.” and “Yes, yes, yes.” Staff had completed training in safeguarding and the provider’s policy guided staff about how to recognise and report abuse. Staff told us they felt confident to raise concerns if they felt people were at risk and action would be taken. One staff member told us, “I follow Beacon’s safeguarding policy, ensure the service user’s safety, report to management without delay and document information accurately.” The principles of the Mental Capacity Act 2005 (MCA) were understood by the registered manager and there were processes in place to review people’s capacity in line with the MCA. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). We found the service overall was working within the principles of the MCA.

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. Care plans provided clear guidance for staff to ensure people received safe, effective and responsive care and support. Risks to people's health, safety and wellbeing were identified, assessed and appropriately managed to help keep people safe. Risk assessments were person-centred, reflected individual needs and preferences, and were regularly reviewed to ensure they remained relevant and effective. Staff received a range of training to support them in recognising, managing and reducing risks. Staff demonstrated a clear understanding of their roles and responsibilities in assessing, managing and mitigating risks. One staff member told us, "I manage risks by following the care plan set out for us as well as the risk assessment completed and use safe working practices throughout. I also identify hazards and report these accordingly.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Prior to support starting, the provider completed an assessment of the environment. This was regularly reviewed to ensure both people and staff were safe. Systems were in place to ensure checks of equipment were undertaken at regular intervals. We asked the registered manager to check information in care plans for service dates matched dates on the tracker which recorded service dates for equipment. The registered manager agreed to implement this immediately. Staff had received training in health and safety and were aware of risks associated with the environment. One staff member told us how they supported people to remain safe, “By maintaining a safe environment with the removal of hazards and making sure equipment is safe to use.”

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. Recruitment procedures were in place, so people were cared for by suitably qualified staff who had been assessed as safe to work with people. However, it was noted employment history for 1 candidate did not provide all required information from leaving school. The provider actioned this immediately. Staff completed an induction on commencement of employment and ongoing training and refreshers to enable them to carry out their role effectively. We reviewed electronic records of visits completed and queried some call details with the provider who provided explanations for anomalies found. Staff, people or relatives raised no concerns about call times, reliability or consistency. One relative told us, “Yes, they have a small team. They’re all very friendly and when people come, [family members] know them all.” Staff told us they felt supported in their roles and received regular support and supervision. One staff member told us, “I receive support through training, supervision and staff meetings. Any concerns raised during supervision or group meetings are attended to promptly by management, which makes me feel supported.”

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. Staff received training in infection prevention and control (IPC) to support safe working practices and effective systems were in place to support good infection control practices and help protect people from the risk of infection. No concerns were raised by staff, people using the service, or their relatives regarding the availability of personal protective equipment (PPE) or the arrangements in place for preventing and managing infections.

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 happened. The provider had a medicines policy, and although the service was working in line with the principles of STOMP (stopping over-medication of people with a learning disability, autism or both), including the use of a tracker to monitor medicines reviews, the policy did not reference STOMP. The provider took immediate action to update the policy to include this information. People were supported by staff who followed systems and processes to administer, record and store medicines safely. People and their families told us that they received their medicines as prescribed and on time. One relative told us, “Before, [family member] was getting it [medication] in blister packs and not taking it so that’s the first thing [staff] do. No issues. It’s 1 thing I don’t worry about.”