The Beeches 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 people were protected from abuse and avoidable harm. This is the first assessment for this newly registeredservice. This key question has been ratedgood.This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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. Accidents and incidents were reviewed and analysed to identify learning and areas for improvement. Lessons learned were shared at staff team meetings. There was evidence of a positive learning culture led by the management team.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider made sure people received consistent support when moving between different services. Information about people was shared appropriately to ensure consistency of care and support.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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 made referrals to the local Safeguarding Adults team when there were concerns about people’s safety, however CQC were not informed about all incidents where safeguarding referrals had been made. We discussed this with the provider and they agreed to review and reflect on their processes. Safeguarding policies and procedures were available to the staff team through a web-based service. A member of staff told us, “All our safeguarding policies are on the website and they are in the office if staff need to refresh themselves on the policies. Telephone numbers are in reception and on the back of each person’s doors. If I suspected abuse, I would complete a safeguarding form and send this to local authority and to CQC.”

We saw evidence the provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. The 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). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. The provider and management team acknowledged they were in the process of reviewing and updating people’s care plans and risk assessments. Current care plans did identify people’s care needs and risks. However, where care plans had been reviewed, we recognised they were more in-depth and personalised when compared to care plans which had not yet been reviewed. The review process for care plans and risk assessments needed to be sustained and embedded to ensure all care plans were as personalised as possible for each person.

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 provider had systems in place to record and monitor compliance and safety checks for the care environment. Information and evidence was well maintained and recorded.

The provider ensured members of staff were qualified, skilled and experienced and who received effective support, supervision and development. Staff teams worked together well to provide safe care which met people’s individual needs. We reviewed recruitment processes and were assured members of staff were recruited safely. We observed, however, there were times where deployment of members of staff was not as effective as it could be. For example, throughout the morning of our inspection there were limited numbers of staff in the main lounge area and minimal engagement for people. We made the management team aware and in the afternoon deployment of members of staff was much improved and we observed a range of interactions and engagements activities for people carried out by members of staff. The improved deployment of members of staff provided a positive atmosphere and happy reactions from people.

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 care home was clean, tidy and well-maintained. Personal protective equipment (PPE) was available throughout the care environment and stock was reordered when supplies were low. Members of staff accessed infection prevention and control (IPC) training and 3 members of staff had been trained as IPC champions. An IPC inspection by the NHS specialist clinical IPC team confirmed the care home was compliant with IPC standards. Family members told us the care home was clean. One relative told us, “Yes [the care home is clean], I can’t complain.” Another relative said, “I have never seen the care home dirty.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Medications were managed, on the whole, safely. We identified pain patch rotation charts and patch body maps were not always completed in line with guidance. This area for improvement had been identified by the provider in their medication audit. We made the management team aware of this concern and we were assured actions to ensure improvement has been identified which needed to be embedded and sustained.