Archived: Bethany Homestead

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Inadequate. At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding systems, the way medicines were managed, staffing deployment, and the oversight of environmental and infection prevention controls.

This service scored 38 (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 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. The provider had not implemented systems to prevent known safety concerns such as incorrectly positioned sensor mats and missed call bells, as these continued to be the case during this on-site visit. Staff did not have the opportunity to learn from incidents and accidents as there was no reliable system to analyse these for themes and trends which meant unsafe practices still occurred. However, the registered manager was aware of these issues and had begun taking steps to address them. Performance concerns were being tackled, and the registered manager had introduced walkaround checks to support more structured monitoring. These actions had not yet led to consistent improvements, but they demonstrated their intent to build a more proactive and accountable safety culture.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. One relative told us they had planned meetings with a health professional at the home, but was unhappy as, “The manager didn’t even turn up for one meeting.” People’s records were not always up to date and did not always reflect people’s current risks or how staff should mitigate them. For example, where people were at high risk of falls, information on how their risks were managed were not always recorded. This meant where people moved between services essential information was not shared, and this put people at risk.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not share concerns quickly and appropriately. The registered manager failed to raise safeguarding concerns where staff failed to follow procedures designed to keep people safe. For example, where staff failed to seek medical assistance for a person who had fallen and was on blood thinning medicines. Records showed, people and relatives told us about issues which would be regarded as a safeguarding concern; however, these had not been reported to the local authority safeguarding team. This included incidents where staff failed to reposition people in a timely way to prevent pressure ulcers and failure to protect people from the effects of the sun. Although staff had received training, they did not have the confidence or experience to report safeguarding concerns. The provider’s safeguarding systems required strengthening to ensure timely recognition and escalation of risk.

The provider did not 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. For example, two people who were not mobile were taken into the garden and exposed to the sun. One relative told us, “On the hottest day of the year staff had put [Name] in the sun, it beggars belief.” The person had become unwell and staff had called 111, the relative recalled, “It’s because [Name] has been out in the sun and staff explained flippantly that [Name] had become dehydrated in the sunshine! [Name] had been sunburned.” Staff had not assessed the risk of exposure to the sun or taken steps to mitigate the known risks.

People were not involved in assessing their risks or understanding what actions they could take to mitigate their known risks. For example, one person at risk of falls tended to move their sensor mat out of the way, which meant staff were not alerted when they were moving around. Staff had not involved the person in managing their own safety. Staff did not always have a clear handover about people’s current needs when these had changed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.The environment was not always safe for people at high risk of harm. Staff did not have a reliable system of identifying when people’s sensor mats were incorrectly positioned or not working due to battery issues. This meant staff were not being alerted by the sensor mats to people mobilising when they were a known risk of falling. Records showed falls continued to occur frequently, and there was no evidence of trend analysis or learning to prevent recurrence.

The registered manager had introduced systems to check all areas of the home daily including access to kitchens, laundry, checking equipment, fire and water safety. However, these checks had been delegated and not carried out daily or in full; and there was no consistent oversight of the environmental checks. This meant during the observation we found that staff had not always identified where fire door alarms were sounding and where fire doors were being propped open, or when pressure mattresses alarms were sounding to indicate a faulty mattress.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff were not always deployed in a way that ensured people received timely and responsive care. During the onsite visit, we observed delayed responses to call bells and inconsistent repositioning of people at risk of skin damage. In some cases, people were told to wait because staff had “More important things to do.” One person told us, “[Staff Name] is always saying to me sorry we are all under pressure today, I will come back later.” People told us they had to wait for their breakfast as there were not enough staff, this meant people did not eat their lunch as they had just been served breakfast. A relative told us, “Well over the last few months I feel that they have cut back on staff, there are too few. You often have to go and find someone if you want to ask a question”. Another relative said, “We do notice that there are fewer staff at weekends and that there are no activities staff around then but overall, I would say there are enough.”

Staff did not always work well together, and they had limited support or supervision from senior care staff. The registered manager had taken steps to address this through disciplinary meetings and supervision of care practice.Staff had been recruited using safe practices and they received induction and training to have the skills to know how to provide care that met people’s needs.

The provider did not always assess or manage the risk of infection. The provider’s infection prevention procedures were not always embedded into routine practice. The registered manager introduced a system of daily checks of the cleaning records, but these checks were not carried out daily and failed to identify that the cleaning records were incomplete. There was no reliable system to identify where people had prolonged periods of loose stools which could indicate an infection. Oversight systems of infection prevention and control were not robust enough to provide ongoing assurance.However, the home was visibly clean, and staff used personal protective equipment (PPE) correctly and demonstrated good hand hygiene and disposal of waste. There were ample handwashing stations and PPE supplies. While there were no outbreaks at the time of out onsite visit, a more consistent monitoring approach was needed to maintain this standard and proactively reduce infection risks.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were significant shortfalls in the safe management of medicines. Staff were unclear when and how to report or seek medical advice for people refusing medicines. The provider failed to have a clear policy or procedure for supplying medicines to people to take when they were out of the home. People were at risk of receiving medicines and creams that were out of date as staff did not record the dates these were opened. Staff could not be assured people received their prescribed creams as planned as records were not consistently completed. Staff did not always have access to the protocols for administering ‘as required’ medicines as these were not reliably available on the electronic medicines system. Where people were prescribed medicines that required additional precautions, such as antibiotics, there were no risk assessments and staff had not been made aware of the potential risks. For example, one person had incurred sunburn from exposure to the sun whilst on photosensitive medicines.

Although staff had completed training and received annual competency checks, there had not been sufficient supervision for staff to develop their knowledge to identify when procedures had not been followed. The registered manager had begun working with external support to address these concerns; however, these actions had not yet led to consistently safe practice. The provider was aware of the issues we identified and had shown willingness to improve. However, people’s health was put at risk as medicine management remained unsafe and required urgent action was needed.