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Archived: Beacon House

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Inspection Summary


Overall summary & rating

Updated 14 July 2017

Beacon House Ministries is a Christian charity established to help homeless people, those in insecure accommodation and those at high risk of homelessness. Beacon House is operated by Beacon House Ministries.

Beacon House offers practical help and a wide range of wellbeing services in Colchester and Essex. As part of this offer, it provides primary healthcare services to adults only. The healthcare clinic provides care and treatment which includes access to health services, physical health, mental health, drugs and alcohol support, vaccination and screening. Health and well-being assessments are offered to all new clients. The clinic is open Monday to Friday between 10am and 2pm.

Our inspection focused on the regulated activity delivered within the health clinic only.

We regulate this service but we do not currently have a legal duty to rate it. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas that the service provider needs to improve:

  • Governance, risk management and quality measurement were not robust and we were not assured the provider was taking a proactive approach to continuous learning and improvement.
  • The CQC had received no notification of change to service delivery in the required 28 days of the change.
  • The registered manager did not demonstrate understanding of the legal responsibilities of the role. The statement of purpose required to be submitted to the CQC informing of change in service delivery was not up-to-date. The CQC had received no notification of this change.
  • There was no formal process for reporting incidents at the time of our inspection. The service developed a draft incident reporting policy in March 2017. This had not been implemented and staff were not aware of this policy.
  • Staff were not completely aware of their role and responsibilities for raising concerns, recording and reporting safety incidents, concerns and near misses, internally and externally.
  • All staff were unaware of the principle of the duty of candour, however, all staff were able to tell us there was a genuine open and honest culture within the service, and this underpinned the ethos of the service.
  • There was no duty of candour policy for the service.
  • There was minimal resuscitation equipment available at the service.
  • The service had a blood glucose monitoring machine which was used to test a patient’s blood sugar. We found this had been serviced, however, this had not been calibrated to the manufacturers instruction. This meant there was a risk of inaccurate readings.
  • We reviewed a selection of medical consumables and medications which demonstrated a proportion of these were out of date.
  • The service recently produced a specimen handling policy, dated March 2017. This policy was not embedded at the time of our inspection and did not include information about the safe and correct process for transporting specimens which staff had to adhere to.
  • At the time of our inspection, staff could not produce a risk assessment or policy for the prevention of risk associated with legionella. Information received after the inspection demonstrated a risk assessment was conducted in 2014; however, there was no evidence of on-going monitoring of the risk.
  • Staff had not completed all mandatory training requirements.
  • Staff had adopted an open door policy for safety purposes, however there was no evidence of a risk assessment which supported this action.
  • The service had developed a deteriorating patient procedure which was dated March 2017. The procedure provided details around the use of an Early Warning Score (EWS) however there appeared to be no details of actions for staff to follow if a patient was identified with an altered EWS. At the time of our inspection, this procedure was not embedded. We were not assured patients would be identified and receive the required intervention.
  • There was no major incident reporting policy in place at the time of our inspection.
  • Personnel files of both registered nurses demonstrated out of date, additional training.
  • The service regularly supervised student nurses and allied health professionals, however no staff in the clinic had completed the mentorship programme. Mentorship involves a more senior or experienced person helping a student to develop clinical competence. It is a requirement of the NMC for students to be assessed and supported by qualified mentors.
  • There was limited evidence of additional training or up-dates related to nurse prescribing in the personnel file and within the appraisal documentation of the registered nurse prescriber.
  • During our inspection we observed other members of staff from the wider organisation entering the clinic environment whilst patient consultations were occurring. This action failed to take into account the privacy and confidentiality of the patients being treated.
  • There was no process in place for staff to escalate disrespectful or abusive behaviour or attitudes at the service.
  • Staff had not received training for caring and meeting the needs of patients living with dementia or learning disabilities.

However, we also found the following areas of good practice:

  • The service had recently moved to an electronic notes system which is commonly used in primary healthcare. This enabled more information sharing with other providers and more information was available to the staff reviewing patients in the clinic.
  • The clinical environment was well maintained and met the needs of the patients and staff.
  • Staff had access to sanitising gel for hand decontamination. We saw staff using this after contact with patients.
  • Staff at the clinic worked with local GPs to provide a coordinated delivery of care for patients who required further care.
  • Staff made referrals to mental health organisations for the patients who attended the service. There was immediate access to a community mental health team for patients who required immediate intervention.
  • The service had clear referral protocols in place so patients could access more specialist services.
  • Staff completed Mental Capacity Act training every three years. Information provided by the service showed staff last completed this training in 2017.
  • We observed staff treating patients with sensitivity and a supportive attitude. Staff demonstrated positive engagement with patients which was free of any discrimination against them.
  • Staff demonstrated sincere compassion and empathy to the patients they provided care for.
  • The clinic did not run specified timings for the appointments given to patients. The staff gave the patient as much time as required for their needs. If the problem was complex, the patient would be given the opportunity to attend for a follow up appointment the next day.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached. We also issued the provider with seven requirement notices that affected community health services for adults. Details are at the end of the report.

Inspection areas

Safe

Updated 14 July 2017

We do not currently have a legal duty to rate one core service for independent health providers.

We found the following issues the service provider needs to improve:

  • There was no formal process for reporting incidents at the time of our inspection. The service developed a draft incident reporting policy in March 2017. This had not been implemented and staff were not aware of this policy.

  • Staff were not completely aware of their role and responsibilities for raising concerns, recording and reporting safety incidents, concerns and near misses, internally and externally. At the time of our inspection, staff did not report clinical incidents through a formal incident reporting system.

  • There was no duty of candour policy for the service.

  • There was minimal resuscitation equipment available at the service.

  • At the time of our inspection, staff could not produce a risk assessment or policy for the prevention of risk associated with legionella. Information received after the inspection demonstrated a risk assessment was conducted in 2014; however, there was no evidence of on-going monitoring of the risk.

  • Staff had not completed all mandatory training requirements.

  • The service had developed a deteriorating patient procedure which was dated March 2017. The procedure provided details around the use of an Early Warning Score (EWS) however there appeared to be no details of actions for staff to follow if a patient was identified with an altered EWS. At the time of our inspection, this procedure was not embedded.

  • There was no major incident reporting policy in place at the time of our inspection.

However, we found the following areas of good practice:

  • The service had recently moved to an electronic notes system which is commonly used in primary healthcare. This enabled more information sharing with other providers and more information was available to the staff reviewing patients in the clinic.

  • Information provided by the service showed staff had completed their vulnerable adults safeguarding training in 2017. This was an annual requirement for all staff.

  • The clinical environment was well maintained and met the needs of the patients and staff.

  • Staff had access to sanitising gel for hand decontamination. We saw staff using this after contact with patients.

Effective

Updated 14 July 2017

We do not currently have a legal duty to rate one core service for independent health providers.

We found the following issues the service provider needs to improve:

  • Personnel files of both registered nurses demonstrated out of date, additional training.

  • Staff completed formal clinical supervision sessions, there was no consistent format, neither the supervisor or the nurse had signed the document and there was no planned date for the next session.

  • One of the staff files we checked did not have a record of the nurse’s personal identification and Nursing and Midwifery Council (NMC) registration.

  • We saw evidence of inconsistent practice with appraisals.

  • The service regularly supervised student nurses and allied health professionals, however no staff in the clinic had completed the mentorship programme. Mentorship involves a more senior or experienced person helping a student to develop clinical competence. It is a requirement of the NMC for students to be assessed and supported by qualified mentors.

  • There was limited evidence of additional training or up-dates related to nurse prescribing in the personnel file and within the appraisal documentation of the registered nurse prescriber.

    However, we found the following areas of good practice:

  • Staff at the clinic worked with local GPs to provide a coordinated delivery of care for patients who required further care.
  • Staff made referrals to mental health organisations for the patients who attended the service. There was immediate access to a community mental health team for patients who required immediate intervention.
  • The service had clear referral protocols in place so patients could access more specialist services.
  • Staff completed Mental Capacity Act training every three years. Information provided by the service showed staff last completed this training in 2017.

Caring

Updated 14 July 2017

We do not currently have a legal duty to rate one core service for independent health providers.

We found the following areas of good practice:

  • We observed staff treating patients with sensitivity and a supportive attitude. Staff demonstrated positive engagement with patients which was free of any discrimination against them.
  • Staff demonstrated sincere compassion and empathy to the patients they provided care for.
  • Staff communicated with patients in a manner they understood. Time was taken to ensure patients understood what was happening and planned and confirmed this when the patient left the clinic. The patient survey conducted by the clinic in March 2017 also supported these comments.

  • Staff made sure patients had the opportunity to ask questions about their care and treatment during and after their consultation.

However, we found the following issues the service provider needs to improve:

  • The clinic followed an open door policy which was in place in the wider organisation.During our inspection we observed other members of staff from the wider organisation entering the clinic environment whilst patient consultations were occurring. This action failed to take into account the privacy and confidentiality of the patients being treated.

Responsive

Updated 14 July 2017

We do not currently have a legal duty to rate one core service for independent health providers.

We found the following areas of good practice:

  • The clinic did not run specified timings for the appointments given to patients. The staff gave the patient as much time as required for their needs. If the problem was complex, the patient would be given the opportunity to attend for a follow up appointment the next day.

  • The patients who used the service were all regarded as vulnerable and the staff at the service worked hard to meet the individual needs of each patient. We saw staff sign posting patients to other services offered by the provider such as the laundry and food bank.

  • Staff told us if the clinic was running slowly or had complex patients that required additional time; staff kept all patients up-to-date with this information.

  • Staff used an online translation service to meet the needs of patients where English was not their first language.

However, we found the following issues the service provider needs to improve:

  • Staff had not received training for caring and meeting the needs of patients living with dementia or learning disabilities.

  • Staff were required to complete equality and diversity training every three years. However, information provided by the service showed no recorded date for staff completing this training.

  • At the time of our inspection the CEO gave us a comments and complaints policy and leaflet produced in March 2017. Staff were unaware of this at the time of our inspection.

Well-led

Updated 14 July 2017

We do not currently have a legal duty to rate one core service for independent health providers.

We found the following issues the service provider needs to improve:

  • We had mixed responses from the trustees regarding the reporting of risks and incidents. We were not assured the board of trustees had oversight of risk or incidents to the service or had the information to have a proactive approach to continuous learning and improvement.

  • There was no formal system to report clinical incidents.

  • There was a lack of process to record the number and type of incidents therefore any actions, themes or shared learning to prevent a re-curing incident was not taking place.

  • There was no formal risk register for the service, however all staff were able to identify risks within the service and inform us of measures taken to mitigate these risks.

  • There was no formalised process for risk assessments.

  • There were outstanding actions following a report undertaken by an external agency in 2014 which provided an assessment of Beacon House continuity plans.

  • The registered manager did not demonstrate understanding of the legal responsibilities of the role. The statement of purpose required to be submitted to the CQC informing of change in service delivery was not up-to-date. The CQC had received no notification of change to service delivery in the required 28 days of the change.

  • The CEO prepared reports for the board meeting. From these reports there was one reference made about the clinic which related to the installation of the electronic patient record system. We were not assured there was a detailed oversight of the governance related to the clinic activity.

  • The CEO had completed a clinical management course to strengthen their leadership ability for the clinical side of the service. However, there was a lack of understanding for the responsibilities, clinical skill and importance of training required for the registered nurses role who ran the clinic.

  • The CEO told us the panic alarm in the clinic was not re-connected following routine electrical work. We were told this was due to the open door policy and did not conform to the open culture of the service as staff did not need it. We did not see any risk assessment or staff communication to support this decision.

  • During our inspection we saw a number of recently written policies which were waiting approval from the board of trustees. Whilst the provider had taken steps to create these policies staff were not aware of them and had not been consulted, they were not embedded into practice and two did not demonstrate clear, clinical guidance for staff to follow. We were not assured patients would be identified and receive the required intervention.

  • Records demonstrated and staff gave us examples of people under the age of 18 who had accessed the service. This could potentially happen again, however, there was a lack of acknowledgment of the importance of having a policy to aid staff in safeguarding this vulnerable group.

  • The trustees we spoke with told us they relied on one trustee to oversee the running of the clinic due to their professional background being medical. This meant there was not a collective oversight of the governance, risk and quality measurement of the clinic.

  • The CEO had poor oversight of the completion of mandatory and additional training required for the registered nurses.

  • The CEO was not aware of this and had no oversight as to when the re-registration of the clinic nurses were due. The staff files were disorganised and incomplete.

  • There were no arrangements in place to respond to emergencies and major incidents for example in the event of a fire or power outage. There was no major incident policy for staff to refer to at the time of our inspection. Staff had not received appropriate training and education on the actions to take in the event of a fire, which included evacuation drills.

However, we found the following areas of good practice:

  • Staff participated in team development days three times per year. Staff we spoke with valued these days.

  • Staff from the clinic had received the Queen’s Nursing Institute award in 2016 for the services provided to this patient group. The Queen’s Nursing Institute award is to honour nurses who have demonstrated a high level of commitment to patient-centred values.

  • The larger organisation had a page on social media which publicised the work they conducted and engaged with the local community, including patients they had previously helped.
Checks on specific services

Community health services for adults

Updated 14 July 2017

We do not currently have a legal duty to rate independent community health services but we highlight good practice and issues that service providers need to improve.