Beeton Grange

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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (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 had a positive culture of safety; however, they were not always proactive in their approach. Lessons were learnt to continually identify and embed good practice, but effective systems and processes were not consistently put in place to reduce the risk of reoccurrence and mitigate risks identified.

Following a safeguarding concern at the service, we raised concerns with the provider during this assessment that they had failed to respond appropriately to reduce the risk of reoccurrence. Although some actions had been taken to address the risk and staff spoken with were aware of these and their associated responsibilities, support plans and risk assessments relating to the event had not been sufficiently updated. One of the arrangements put in place to fully protect the person was informal with no credible oversight to reassure the provider that robust action had been taken to keep the person safe from potential harm. We also noted another incident that had taken place which involved a person placing themselves at harm. Immediate action was taken to support the person and obtain medical help and advice. Staff spoken with were also aware of the risk and how to mitigate this. However, the related risks to the person had not been reviewed in a thorough or comprehensive manner. Both these events were bought to the attention of the management team who took action to address these failings.

We observed people were supported by staff who knew them well and listened and responded to their concerns.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Pre-assessment processes were in place and people were involved in decisions about their care. Staff reported they were provided with the necessary details regarding people’s care needs and how to support them prior to people moving into the service.

Staff also advised us handovers were comprehensive and good systems of communication were in place to ensure information was shared across shifts. A member of staff said, “We get lots of information, the manager will do an assessment and get paperwork for us.”

A healthcare professional told us, “They [care staff] make sure everything is in place and information is readily available.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and to the appropriate authorities.

Following a recent concern being raised and responded to by the police, the provider had failed to raise a safeguarding alert with the local authority. This was completed after the registered manager had spoken to a CQC inspector who made enquiries regarding the original event. Following this conversation, a safeguarding alert was raised with the local authority and actions were taken to mitigate the risk of re-occurrence. This event itself, in part, prompted the assessment of the service.

Staff had received training in how to recognise signs of abuse and were aware of the actions to take should they be concerned a person had been placed at risk of abuse. Staff spoken with were confident that management would respond to any concerns raised appropriately. A relative told us, “I feel [loved one] is safe and well cared for.”

A member of staff described a safeguarding incident and informed us of the actions that had been taken in response to this. We saw the staff member’s concerns had been recorded appropriately, and actions were being taken to investigate the concerns raised and alert the appropriate authorities to the allegation of abuse.

We observed people appeared to feel safe in the presence of staff and approached staff for support and guidance.

The provider did not always work well with people to understand and manage risks. Effective systems were not always in place to enable staff to meet people’s needs and mitigate the risks to them.

People were supported by staff who knew them well and were aware of the risks to them and how to minimise those risks. However, the assessment and management of risks was not always as thorough and comprehensive as it could be. For example, following a recent concern, the support plan and risk assessment put in place for 1 person was confusing and did not robustly address the risks identified for that individual. Actions had been taken to address the risk to the person, but effective processes were not in place to ensure some of these actions were taking place. We also found that following an incident with another service user, a support plan and risk assessment had not been fully updated to address the risk identified. These concerns were bought to the attention of the management team during the assessment and actions were taken to address the concerns raised.

A weekly one-to-one meeting took place with people and their key workers, enabling people to communicate their needs, emotions or distress. These meetings varied in content each week, providing people with the opportunity to discuss daily living skills, social networks, managing mental and physical health, medication, self-care, confidence and relationships.

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.

We observed the environment was clean, bright, spacious and people’s rooms were decorated in a person-centred way to reflect their personality and individual choices.

However, we noted the fire exit from the garden was cluttered with mattresses, creating a potential fire risk. This was bought to the attention of the management team and action was taken to immediately remove the risk. We also noted on 1 occasion the door to the medication room was left on the latch. The medicine cabinets were locked but a new month’s supply of medication had been delivered and left unsecured inside the unlocked medicines room. Therefore, these medicines were potentially accessible to service users, staff and visitors. This was bought to the attention of the management team and actions were taken immediately to reduce the risk of reoccurrence.

Staff confirmed fire drills took place and they were able to explain the actions they would take if the fire alarm went off.

The service had benefitted from a number of environmental changes that had taken place at the service earlier in the year. Staff commented on the positive impact the environmental changes that had taken place had made to the people living and working at the service. A member of staff told us, “It’s a lot better, the building has changed, it’s a cleaner environment and a happy place to work in. People here are more uplifted and inviting family members round and people are trying to keep their spaces clean now. Before it wasn’t bright and spacious.”

The gardens were accessible, and a smoking shed was in place, which was a good distance from the home itself. A relative told us, “It’s so much better since the renovation has been done. I’m happy to visit and it’s cleaner. [Love one’s] room is more organised and up to date.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff told us they had no concerns regarding staffing levels and we observed people were responded to in a timely manner. The majority of staff confirmed they received regular supervision and an annual appraisal, and all staff spoken with told us they could approach the registered manager for additional supervision meetings if necessary. Records seen demonstrated staff received regular supervision.

There was a training matrix in place which provided the registered manager with oversight of staff training levels. Staff told us they felt well trained and had their competencies assessed. One member of staff told us, “A lot of training is online, and we get an email to remind us.”

Initial records shared with the inspector demonstrated that only 2 staff had had their competencies assessed in respect of supporting people at risk of choking. When this was queried with the registered manager, we were advised the current information was not up to date. Assurances were later provided by the regional manager to confirm the majority of staff had their competencies assessed in this area.

Staff told us they received an induction that provided them with the training and support they needed to do their job. One member of staff told us, “Every day you are learning in the sector, it’s training as you go along basically.”

People were supported by staff who had been safely recruited. Staff received an induction which included mandatory training and shadowing more experienced staff. A member of staff said, “When I came here, I did a couple of days training and staff introduced me to people and showed me what to do, the manager checked in with me and did a one-to-one as well.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

It was noted the environment was clean and clutter free. Staff advised us there were plentiful supplies of personal protective equipment (PPE) available to them. People were supported by staff who had received infection control training and had their competencies assessed.

Staff spoke positively regarding the recent refurbishment of the building and all commented on how much cleaner the environment was.

A relative told us, “The kitchen is immaculate, clutter free and well organised.”

The provider did not always make sure that medicines were stored securely. Medicines and treatments in place met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were supported to receive their medicines by staff who had been trained and had their competencies assessed. There was a dedicated medicines storage room. However, during a walk round of the service, we noted the medicines door had not been locked and had been left on the latch. This placed people at potential risk of harm and was an additional security concern as the side gate of the building was accessible to the public. We immediately raised this with the management team. Action was immediately taken to ensure the door was locked in future. Arrangements were made following the assessment for the medicines door to have a keycode system in place to reduce the risk of this happening again.

Each person had their own medication care plan in place, providing detailed information regarding each medicine and any allergies. Medication audits were in place to identify any potential medication errors. Where people required medication as and when required, protocols were in place to direct and guide staff regarding the circumstances in which these medications should be administered. Staff were able to describe the circumstances in which they would administer ‘as required’ medication and what they told us was reflected in people’s support plans.