Beaumont Manor

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 the ways people’s medicines were managed safely and in relation to assessing risks.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Systems in place at the time of our assessment meant the provider could not fully demonstrate a proactive and positive culture of safety. A new management team were in place, and records clearly showed they discussed safety events at regular staff meetings and had developed lessons learned documents to support staff to continually identify and embed good practice. However, although staff listened to concerns about safety and investigated and reported safety events, there was a lack of overarching formal analysis to show themes and trends in accidents, incidents and safeguarding matters to reduce the risk of reoccurrence. The provider had already identified improvement was required in this area and had invested in a new electronic incident reporting system, to ensure robust oversight going forwards.

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. People received a pre-admission assessment before joining the service, to ensure their needs could be met. A relative told us, “[Person] arrived there this last Monday. [Person] was assessed in hospital and [staff] went to see [person] down there, they have been very good.” Admissions and discharges were discussed at weekly clinical risk meetings. The management team also proactively fed back where there were issues within wider systems, such as problematic discharges for people returning from hospital, to help keep people safe.

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 shared concerns quickly and appropriately. Staff received training in safeguarding, and were confident leaders would act on concerns raised. A staff member said, “I fully know how to escalate any safeguarding issues to the safeguarding lead, and if I felt that it wasn’t dealt with appropriately, I would go to the local authority.”

Whilst people told us they felt safe and secure, the provider did not always work well to understand and manage risks, due to improvements needed to systems for completing care records. Care plans and risk assessments were stored partly on an electronic system and partly on paper. Nationally recognised tools were used to assess risks, such as Waterlow (for the risk of pressure ulcers) and MUST (malnutrition risks). Whilst risks were identified and assessed in a wide range of areas including mobility, choking, skin integrity, and specific health conditions, information was not always consistent, clear or up to date. A staff member told us, “Sometimes it is not accurate, it needs updating.” For example, we found multiple care plans which referred to different types of modified diet for people at risk of choking, which could be confusing for staff. Another person’s care records did not clearly set out the support and correct equipment they needed to move safely. We asked for these records to be reviewed. The provider was open and transparent about the need for improvements in this area and planned to move to a new electronic care planning system imminently.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Health and safety checks were carried out to make sure the environment was safe and fit for use. The provider had also considered how to ensure a dementia-friendly environment, and plans were in place to further enhance the service to meet people’s sensory needs. Risks were assessed to reduce the risk of slips, trips or falls, including where people brought their own furniture if they chose to do so. A relative told us, “[Person’s] room is clean, very bright and [person] can have [their] own belongings there. [Beaumont Manor] were fine with that, so this charming man (maintenance) is hanging things on the wall for [person].” Another relative said, “No [mobility] equipment is used, other than [person’s] walking frame, and that is clean.” However, we found some people’s Personal Emergency Evacuation Plans (PEEPs) needed to be updated. We raised this with the provider for review.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Whilst recruitment practice was safe, and staff received training and supervisions, we received mixed feedback about staffing levels. A staff member told us, “The staffing levels are inconsistent.” Another staff member said, “I would like more staff, at times it can be quite chaotic.” The service used a dependency tool to calculate staffing and told us this was updated in response to changes in people’s needs, for example an increase in falls. However, we received feedback from people and their relatives that nurse call bells were not always answered in a timely way, and this was confirmed by the provider’s own audits. A relative said, “Sometimes there are plenty of staff, but oftentimes I hear buzzers going off and not being answered. Sometimes it feels very quiet and calm, other times not.” Another relative said, “I believe it is hard to get hold of staff at night time.”

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. We observed the service was clean and hygienic throughout, and there was a dedicated housekeeping team in place in addition to care staff to ensure good infection control. We received some mixed feedback about the laundry. For example, a relative told us, “Clothing is often lost or misplaced and sometimes towels have not been replenished in [person’s] room and when I have asked for 1 there were no clean ones available.” At the time of our assessment, a new labelling system for clothing was being introduced. Staff had access to personal protective equipment (PPE) to reduce the risk of infection. One relative told us, “It is clean and tidy.” Another relative said, “PPE is worn.”

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, and care plans and risk assessments were not always in place. A new electronic system for the administration of medicines had just been introduced the day before our visit. The staff were still learning how to confidently use the system, and so were not yet in a position to demonstrate the impact of the new system on people’s safety. Paper records we checked for the previous month showed people were not always having their regular medicines administered appropriately. We found that medicines had not been signed as given on multiple occasions and these had not been investigated. This included critical medicines such as those to treat seizures, Parkinson’s disease and antipsychotics. Some people who had been asleep during the morning medicine round were not offered their medicines later when they woke up. A new dashboard within the electronic system showed oversight of any missed medicines to allow daily follow up.

Controlled drugs were stored in the treatment room, but the keys were not always secure.Equipment used to help administer medicines, such as the tablet crusher, was not clean and some medicines had expired. The treatment room was too warm, which could impact on safe storage of medicines. We saw medicines patches were recorded when applied but there was no daily check taking place to ensure they remained in place. One person receiving covert medicines (medicines administered without their knowledge in their best interests) did not have all the correct information and authorisations in place to ensure the safe administration of their medicines. Following our inspection the provider contacted the GP to ensure that all covert administration was reviewed.

Staff had completed medicines training and had their competency assessed. Some medicines incidents were being reported and investigated, but issues found during our inspection had not been reported. Managers were completing audits regularly and taking actions on issues they identified. The electronic administration system had been installed ahead of schedule to improve processes and allow manager oversight of the administration of people’s medicines.