Beechcroft 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. The last rating for this key question was good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 positive culture of safety and honesty. There were systems and processes in place to manage accidents, incidents, and complaints. The registered manager investigated these, discussed with staff and developed plans for improvements. Changes were made to the service delivery and staff refresher training was arranged when needed. Staff told us, the registered manager discussed potential concerns with them and enabled learning opportunities. People and their relatives were consulted about their care and improvements that were carried out to the premises.

The provider worked with people and external professionals to maintain safe standards of care. They ensured continuity of care, when people moved between different services. They supplied relevant information about people’s healthcare needs to external professionals. This helped to ensure safe care for people when needed.

People were protected from the risk of avoidable harm, neglect, and abuse. People using the service and their relatives told us they felt safe when receiving care from staff. One person told us, “They [staff] are very safe and careful.” Another person said, “They [staff] are gentle, and I know they would never hurt me.” A relative commented, “You can’t fault them [staff], we are very happy with care.” The provider policies and procedures in place for safeguarding adults from abuse.

The registered manager and staff understood the different types of abuse, and the signs to look for. Staff were aware of the action to take if they suspected someone had been abused including reporting their concerns to the registered manager, the local authority safeguarding team, and the CQC. Staff completed safeguarding training. They knew the procedure for whistle-blowing and said they would use it if they needed to. Safeguarding concerns had been raised, the provider worked effectively with local authorities and health and social care professionals, to address concerns and they notified the CQC of these as they were required.

People consented before staff supported them. Staff knew about people's capacity to make decisions through verbal or nonverbal means, and this was well documented. We found the service was working within the principles of the MCA and appropriate legal authorisations were in place to deprive people of their liberty. People and those important to them were involved in best interest meetings.

People were protected from avoidable harm. The registered manager and nursing staff completed risk assessments and risk management plans that included guidance for staff. For example, about how to manage pressure ulcers, mobility, falls, eating and drinking and the home environment. One person said, “They [staff] have to help me because of my health condition, and I can trust them.” One relative told us, “Over the time my [loved one] has been here, many of them [staff] have become our trusted friends.”

Risk assessments were reviewed periodically or as and when people’s needs changed. However, some sections of plans for people who were new to the service were found to be incomplete. For example, information about their emotional and mental health needs was often missing. There was not enough detailing of conditions such as dementia, complex mental health diagnoses including schizophrenia, and depression. Following the inspection t feedback, the registered manager and their team completed more detailed plans straight away and sent us supporting documents to show that they had addressed these issues.

We saw staff supporting people to move, including using equipment, and caring for people in a safe way. They were gentle, followed appropriate techniques and gave people the information they needed to stay safe.

People's care and support was provided in a safe environment. People were able to bring their own belongings to decorate their rooms. One person told us, “I have a walking frame and there are notices all over the place about fire.” In some parts of the premises refurbishment and redecoration work was in progress. There was a risk assessment which was in place to ensure the environment remained in good condition. Staff and external agencies, where necessary, carried out safety checks of the equipment, on the premises and the safety of appliances.

The provider had arrangements to deal with emergencies. People had personal emergency evacuation plans (PEEPs) in place which gave guidance for staff and the emergency services on the support they would require evacuating from the service safely.

People were supported by effectively deployed staff. One person said, “There are enough staff, even though they [staff] do work hard.” One relative told us, “They have enough staff, and I pop in and out at all times and have not seen them short of staff.” Staff told us they felt there were enough staff to meet people’s needs safely. The registered manager told us they carried out assessments to determine people’s staffing needs and had good staff retention.

The provider supported staff through induction, supervision, training, and appraisal to ensure they had the appropriate knowledge and skills to meet people’s needs. One person said, “They [staff] all seem to know their job.” One relative told us, “I think they [staff] are well trained, they always are able to answer any questions I have and explain.” Another relative commented, “I think it must be good as they [staff] are confident as well as kind.” Training records confirmed staff had completed a range of trainings including refresher courses that was relevant to people’s needs.

The provider carried out satisfactory background checks for all staff before they started working. These included checks on staff members’ qualifications and relevant experience, their employment history and consideration of any gaps in employment, references, criminal record checks, proof of identification, and current registration with professional bodies for nurses. This reduced the risk of unsuitable staff working with people who used the service.

People were protected from the risk of infection. Staff understood the importance of effective hand washing, using personal protective equipment (PPE) and disposing of waste appropriately. This protected people from infection and cross-contamination. The service had infection control procedures in place and records showed that staff had completed infection control training to ensure they knew how to prevent the spread of diseases.

People received their medicines as prescribed.One person told us, “They [staff] give me my medicines”. We looked at 6 people’s medicines and found no discrepancies in the recording of medicines administered. However, we found that Medication Administration Records (MAR) charts had duplicate medicines that had been crossed out without a second authorised signature (in line with NICE guidance). In response to our feedback, the registered manager made improvements straight away. Overall, this provided a level of assurance that people received their medicines safely, consistently and as prescribed.

During the inspection, we saw several instances of where residents were prescribed PRN (as required) medicines and there were associated PRN protocols in place. We only found 1 record where a PRN protocol was not in place. In response to our feedback, the registered manager made improvements straight away. This meant we had overall assurance that staff were able to administer these types of medicines effectively to residents, within appropriate clinical guidance.

There was a homely remedies procedure in place at the provider, with appropriate authorisation and oversight by the GP. No one was managing their own medicines (self-administering) at the time of our inspection. One person had their medicine administered to them covertly. Although we saw evidence of a best interests meeting in place, we did not see any authorisation documents signed by the GP, pharmacist and Next of Kin to ensure that this medicine could be administered safely in a covert manner. In response to our feedback, the registered manager made improvements straight away and sent us supporting document to demonstrate they had addressed this issue.

Medicines were safely managed. There were systems for ordering, administering and monitoring of medicines. Staff were trained and deemed competent before they administered medicines. Medicines were safely secured, and records were appropriately kept. We found that room and fridge temperatures were appropriately monitored.

The provider had a system to monitor and audit people’s medicines on a regular basis, and we found that improvements had been made as a result of this. For example, a monthly audit by the provider found that opening dates should be written on liquid medicines and during our inspection, we found this to be the case.

We were assured that medicines related incidents were investigated properly with appropriate action plans and there were processes in place to ensure staff learned from these incidents to prevent them occurring again.

There were separate charts for people who had medicines such as patches, ointments and creams prescribed to them (such as pain relief patches) and there was an appropriate medicines policy in place. Furthermore, medicines for waste were disposed of regularly and appropriate records were made.