Bell House Care Home Limited

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 service was in breach of legal regulation in relation to safe care and treatment.

This service scored 25 (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. Lessons were not learnt to continually identify and embed good practice.

Robust systems were not in place to support a positive learning culture in the service. There was no overall analysis of incidents, and this resulted in missed opportunities to identify trends, implement learning, and prevent future harm.

Staff failed to complete accident forms accurately. For example, 1 accident form documented the event ‘was’ and ‘was not’ witnessed. Inaccurate documentation was not identified by the provider, demonstrating a lack of oversight of accident records to mitigate future risk and create learning opportunities for staff.

The provider failed to make appropriate and timely referrals, including delays regarding notifiable incidents to the Care Quality Commission (CQC). This resulted in a failure to fully investigate the incident and identify any learning.

Concerns had been raised to the provider, and these had not been referred to appropriate organisations. The provider told us, “The concerns had not been recorded.” The service failed to protect a person from abuse by not documenting and acting on the concerns raised.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The provider failed to ensure there were robust and safe systems in place to effectively manage people’s safety. For example, professionals told us staff had incorrectly identified a person to a visiting heath professional. This resulted in a person receiving treatment which was not intended for them. The service failed to notify CQC of this incident.

Professionals told us the provider did not always provide the requested medical samples for people; putting people at risk of delayed treatment.

The provider had made some medical referrals for people; however, these were not consistent and there was a lack of effective communication with external professionals.

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. The provider did not share concerns quickly and appropriately.

There was a lack of robust and effective safeguarding processes in place. The provider did not have up to date safeguarding legislation in place. There were repeated failures relating to the protection of people from harm or abuse. We found multiple incidents which met the threshold for reporting to the Local Authority and CQC, for example, falls leading to significant injuries. However, the provider had not done this.

Staff did not identify certain behaviours and incidents as potential abuse. Staff had received training in managing distressed behaviours; however, staff did not show competence to keep people safe. This meant the opportunity to prevent physical harm to people was missed.

The provider failed to protect people from harm and mitigate any future risk of harm. People told us they felt safe; however, documentation did not support this.

There were no robust systems in place regarding best interest decision making and Deprivations of liberty safeguards (DoLS). People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA, 2005). In care homes, and some hospitals, this is usually through MCA application for DoLS. Best interest decisions were not completed in line with legislation, and people were unnecessarily deprived of their liberty. The provider has advised us how they plan to improve safeguarding processes in the service.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People with specific medical conditions did not have appropriate documentation in place to support safe management if their health, for example care plans or risk assessments. There was no guidance for staff regarding how to manage risks associated with specific medical conditions, including contact details for relevant professionals. This demonstrated a failure to assess, monitor and mitigate a known risk, and involve relevant professionals.

The provider failed to carry out accurate best interest decisions in line with legislation and best practice. We identified best interested decisions principles were not followed, for example, inclusion of people’s relatives and relevant professionals in decision making.

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 environment was not consistently safe which put people at risk of harm. For example, the garden area was unsafe for people to access. Risks relating to accessing the garden had not been mitigated and relevant risk assessments had not been considered for people.

People’s bedrooms were not always kept to safe standards. For example, leaks in bathrooms, radiators not attached safely and unsafe flooring. Environmental audits failed to identify these concerns. The provider failed to ensure the environment was safe which placed people at risk of harm.

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.

The provider did not ensure robust recruitment systems were in place. Staff did not have the necessary pre-employment checks in place, such as a relevant police checks, to ensure staff were safe and competent to fulfil their role. The provider failed to ensure there were robust systems to ensure staff were safe to care for people within the service, which placed people at risk of harm.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There were strong odours throughout the service. Daily cleaning tasks, including the communal areas, were not always completed due to a lack of regular cleaning staff. There was minimal cleaning supplies available and Personal Protective Equipment (PPE) was not always safely stored. Staff also struggled to locate PPE. The provider failed to ensure there were robust infection, prevention and control (IPC) processes in place to protect people.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medication was not stored safely. Out of date medication which had been expired by at least 1 year for people. Medications had been accepted into the service which were already out of date. There was no evidence this had been checked by staff.

There had been a previous leak in the medication fridge, causing medication to have pharmacy labels which were not readable. The provider failed to replace the fridge, knowing there was a risk of a further leak occurring.

Medication audits were completed; however, these did not identify storage concerns which placed people at risk of harm.

Medication care plans did not consistently reflect people’s needs. Care plans and Medication Administration Records (MARs) did not identify medication safety issues, such as people who had allergies. This placed people at risk of harm.

PRN (as and when required) medications were not managed in line with the provider’s medication policy. PRN protocols were not updated following a change in need, putting people at risk of being administered incorrect medications.