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.