Bere Grove 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. 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 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always sufficiently learnt to continually identify and embed good practice.

Records did not always demonstrate incidents had been fully investigated, or lessons learned to improve care. For example, after a fall, when a person sustained an unexplained bruise and where there were concerns a person may have sustained a minor injury involving moving and handling equipment. Although some measures were introduced to improve safety, we did not find this in relation to all incidents. Records also showed when 1 person became distressed, sufficient action had not been taken to ensure staff learned from this to improve support. The registered manager acknowledged these concerns and outlined plans to strengthen practice.
Some processes to support learning were in place. The provider employed a regional clinical development nurse who supported leaders with monitoring for areas such as falls and fluid intake. They had identified the need to improve fluid monitoring and had begun to take action; however, these changes were not yet fully embedded, and this remained an issue at the time of our inspection.

However, other incidents had prompted improved and safer care. For instance, equipment had been introduced for a person who had fallen out of bed, reducing the risk of harm. Staff also told us of learning practices. For example, 1 staff member said, “When people have incidents, we have lessons learned sheets. If there is a need they are handed out. For example, with medication errors they [senior staff] fill out the lessons learned form.”
 

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 effectively assessed prior to their admission. Pre-admission assessments were detailed and personalised and people and their relatives told us they were involved in this process. The provider ensured key information was shared with the heads of departments daily and to staff during their shift handovers. A staff member told us they received enough information about people to support them safely.

Information about people was communicated effectively when people went to hospital.

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.

People and their relatives told us people were safe at Bere Grove. For example, 1 person said, “Staff help me a lot and that’s why I feel safe.”

Staff completed safeguarding training and had policies and procedures to support them.Staff understood how to keep people safe and were confident if they reported concerns about potential abuse to leaders, these would be taken seriously and acted on appropriately.

There was a positive and welcoming atmosphere in the home and people appeared relaxed with staff.

Where people needed to be deprived of their liberty to keep them safe, the service ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority.

The provider did not always work well with people to understand and manage risks.

Moving and handling risk assessments were not detailed enough to provide effective guidance for staff. Staff did not always provide consistent feedback about how some people were supported to mobilise. Although we did not identify people had come to harm as a result, poor record keeping increased the potential risk of people suffering future harm. Other risk assessments provided personalised and detailed guidance such as skin integrity and catheter care.

Records did not always demonstrate risk mitigation guidance was followed. For example, in relation to fluid intake and distressed emotions. The provider had recognised this and had plans in place to address the risk.

Staff had variable knowledge about how to manage people’s risks. However, there were several new staff members and additional training had been booked. Staff told us there was always a more experienced member of staff they could call on if needed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises was secure, well maintained and safe. Safety equipment such as window restrictors were in place throughout. Safety checks had been completed as required in relation to fire, gas, electrical, water and equipment safety. Staff told us there were processes to report environmental concerns which were acted upon promptly. Staff had completed relevant training for example, in relation to fire safety and the safe use of bed rails.

The home was decorated to a high standard, had a variety of areas for people to enjoy and was suitable for the people who lived there. The environment promoted safety. For example, corridors were wide with handrails and lighting in bathrooms was automatic, which helped minimise the risk of people falling. Consideration had been given to people who lived with dementia. For example, there were themed areas to help people orientate around the home and toilet doors were blue which helped people recognise these. Leaders told us they would consider further signage to enhance orientation.

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.

Staff were recruited safely and required pre-employment checks had been completed.

People, relatives and staff told us there were enough staff to meet their assessed needs. For example, a person told us, “Staff are always there when I need them. They check on me at night too.” We saw staff supported people when they needed it and call bells were answered promptly.

Staff were positive about the training they received. One staff member told us, “I think the training is good. We have regular updates.” Some staff provided examples about how they had been supported to develop and progress within the company. For example, 1 staff member said, “I started as a host, then a carer, a senior, a care practitioner and now I’m the deputy manager. I’ve been really supported to develop.”

There were some areas where people with dementia could benefit from enhanced support to improve their experience. For example, with lunchtime. This had been recognised by the provider and on our first day of inspection, training and support was being provided by the organisation’s dementia specialist.

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.

The provider’s infection prevention and control processes reflected good practice guidance. The provider had an infection control champion and staff understood how to prevent the spread of infection. Staff were observed to wear appropriate personal protective equipment (PPE) and removed and disposed of it correctly.

Processes were in place to audit the effectiveness of the infection prevention and control processes, staff training, and rates of infections within the home.

We observed the service was clean throughout. However, on the 1st day of our inspection, there was malodour upstairs. By the 2nd day of our inspection, this was gone and the home smelt fresh throughout. The registered manager told us they had implemented processes to ensure this did not happen again. People and their relatives were complimentary about the cleanliness in the home. For example, 1 person told us, “The home is spotless, staff work very hard.”

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

Shortfalls were identified with some medicine documentation, including the accuracy, completeness and detail of PRN (as required) protocols and medicine profiles. We discussed our concerns with staff who updated these records, but further improvement was still needed with PRN protocols. For example, 1 person’s PRN protocol directed dosing based on levels of distress without defining how these presented for the person. This meant staff may not have clear guidance to support consistent decision-making. Although staff demonstrated a good understanding of how to meet people’s needs, the lack of personalised records meant there was a risk of inconsistent practice and inappropriate or delayed administration, particularly if unfamiliar staff were required to administer these.

Other records demonstrated people received their regular medicines, including time sensitive medicines as prescribed.

We observed staff administered people’s medicines safely, in accordance with individual preferences.

Medicines were stored securely and only administered by staff who were suitably trained.

There were effective systems in place for the receipt and return of medicines. Regular audits were completed, and these showed medicines were consistently accounted for, demonstrating effective oversight and governance of medicines management.