Archived: Beeches Care Home (Nottingham)

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.

The service was in breach of legal regulation in relation to safe care and treatment and requirements relating to mental capacity.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Whilst there were some processes in place to encourage lessons to be learnt, we found examples of repeated errors that placed people at risk. We observed a safety incident on site and raised this with management; however, we observed it occurring again later that day. Incidents were not always investigated, for example for the past 6 months there had been 44 incidents, however only 4 were analysed in depth to find the root cause and address it.

The provider was reactive to feedback and encouraged it, however there was little evidence of a proactive approach.

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 provider had told us they had improved the pre-admission assessments at the home to ensure they could meet people’s needs. However, people told us they were not involved in their own care planning. Not everyone had emergency grab sheets to ensure continuity of care and critical information in people’s care plan was not always accurate. Records we reviewed had conflicting information and guidance for staff to manage and monitor people’s safety.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People we spoke with told us they felt safe living in the home and with the staff. Although one person felt they needed to keep an eye on other people when staff were not in the lounge area.

Some people at the service were subject to a Deprivation of Liberty Safeguard (DoLs), this is where a person cannot make decisions about their care and treatment. Other people had been assessed to lack capacity under the Mental Capacity Act (MCA). However, we found people’s DoLs authorisations were not clearly documented, and people had restrictions in place without decision specific MCA assessments, therefore this placed people at risk of receiving treatment without consent or in their best interest. Covert medicines were being used for one person with no authorisation to do so in place. Whilst staff had completed training on MCA, their knowledge was still limited and did not fully understand the impact of MCA and DoLs on people. This meant people’s human rights may not have always been respected or protected.

The provider did not always 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.

People’s care plans around identified risks, such as support with catheter care, gastronomy tube and oxygen, were inconsistent and did not provide clear guidance for staff to follow which placed people at increased risk of harm. We did raise this with the provider, who took prompt action to address the concerns.

Where people were at risk of skin breakdown plans were not clear on how to support them with repositioning and recording of repositioning was not consistent. Risk assessments had not always been completed which meant some risks may not had been identified or managed effectively.

People and their families told us they were not involved in reviewing their risks.

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.

Environmental checks to ensure people lived in a safe environment, such as water temperatures and fire safety were not always completed. People’s personal emergency evacuation plans did not accurately reflect the people in the building and lacked detail to enable staff to support them safely in an emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

People felt their care had been previously impacted due to staffing levels and high use of agency staff; however, they did feedback to us it had improved recently. People said, “I think it’s improved in the last few months. They used to be lack-a-daisy when I first came 7 months ago,” and “They get some from an agency and we have to tell them what we need doing.”

Whilst the provider did calculate their staffing levels based on their clinical risk register, people described to us they sometimes had to wait a long time to be supported. They said, “It can be a bit of a wait, if they come at all. I’ve had them turn it off sometimes, say they’ll be back then that’s it,” and “They leave me with a wet pad for too long - it happens quite often. They don’t think to check unless I say I feel wet.”

The provider was aware of the issues with staffing and had been recruiting to vacancies leading to a reduction in the use of agency staff.

Recruitment processes were followed to ensure only suitable staff were appointed. Checks including, interviews, references and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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.

People said they felt the home was kept clean and our observations confirmed this. Staff were trained in infection prevention and control, and we saw them using personal protective equipment appropriately.

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

Some people were supported with creams, such as barrier creams, however we found open dates and expiry dates were not always being recorded, this placed people at risk of being supported with creams with reduced effectiveness.

We raised concerns with the provider regarding the labelling and storage of insulin, which they addressed immediately.

We observed medicines people had ‘as and when’ required, such as inhalers or pain relief, were not always offered to people.

Controlled drugs were managed safely, with appropriate recording and storage in place and correct processes were followed for prescribed medicine administration.