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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm. The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation. The provider was also in breach of the legal regulation relating to safeguarding and consent to care.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. For example, where audits identified fire and water safety checks had not been completed, actions had not been followed up and systems had not been reviewed to prevent further occurrences. Lessons were not learnt to continually identify and embed good practice. For example, incidents such as falls were not always recorded in detail or analysed to identify themes to learn from and prevent further incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The manager had identified the need for improvements and was working to establish better relations with partners to ensure smoother transitions and continuity of care. This included a system to ensure people going to hospital had all their relevant information with them and then reassessed prior to their return to ensure the service could still meet the person’s needs However this needed time to be fully embedded.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. For example, the manager had not implemented the instructions from safeguarding investigations to have all staff re-trained in dignity in care, placing people at continued risk of abuse. Safeguarding systems, processes and practices did not reflect the manager and staff had good understanding of the Deprivation of Liberty Safeguards (DoLS). For example, one person’s DoLS conditions had not been implemented since they had been instructed by the DoLS team in September 2024. We brought this to the attention of the manager who needed guidance from the inspection team on how to meet the condition. This placed the person at risk of deprivation of their liberty without the legal safeguards in place.

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, staff were not always vigilant in ensuring people who required walking aids and supervision to mobilise were supported; staff handover and people’s daily notes did not reflect when people had required additional support. This placed people at increased risk of falls. We were not assured peoples’ risks associated with their food and drink consistency to prevent choking and aspiration were managed. For example, kitchen and care staff did not have clear information about peoples’ dietary needs at the time of serving and providing meals. This placed people with specific dietary requirements at risk of choking or receiving food and drink that was not suitable for their health conditions.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The provider did not have the systems in place to identify people had access to kitchens, laundry, car park and cleaning cupboards; people were placed at risk of harm from hot water, hot appliances, cleaning materials, cars and laundry equipment. We brought this to the attention of the manager who took measures to prevent people accessing these areas, however, these measures have not been embedded into practice. The provider failed to have robust systems to ensure all water and fire safety procedures were implemented and followed, placing people at risk of harm from hot water, water that is not clear of Legionella bacterium or kept safe in the event of a fire.The manager had completed all actions required in the fire risk report such as installing new fire doors. The manager had updated the security of the home by installing key codes on the exits and entrances.

The provider did not 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 work together well to provide safe care that met people’s individual needs. People were at risk of receiving care from staff that had not been proven to be of good character as two staff had not undergone all the recruitment checks such as Disclosure and Barring Service (DBS) checks. DBS checks ensure staff did not have any criminal convictions and were suitable to provide support for the people living at the service. Staff were not always deployed to meet people’s needs in a timely way as call bells were not answered in a timely way, leaving people to wait for their personal care and not have their needs met.The manager recognised there were shortfalls in staff competencies and took action to provide training to improve environmental safety and recording incidents and accidents, however, these had not all been embedded into practice.The manager had implemented systems to record staff training and supervisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Although staff had received infection prevention and control training, we observed staff not following infection prevention procedures as they did not always remove all personal protective equipment before leaving people’s rooms following personal care. This placed people at risk of cross infection. Staff did not have a system to record or monitor the regular cleaning of equipment such as slings used for hoist transfers. The home appeared clean, and staff told us they had all the equipment they required. The manager had introduced an infection prevention and control champion and cleaning to night shifts, however, these had to be embedded into practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People’s supporting risk assessments and care plans did not include people’s mental capacity to agree to their medicines or what to do if they repeatedly refused their medicines. The provider had implemented a new electronic system for managing medicines, which had reduced the number of incidents and staff told us the systems were safer.