Beige Healthcare Services

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 59 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

Staff told us if they had concerns, they would report to the manager who would escalate further when required. They told us, “[Registered manager] has been very helpful, easy to communicate with, responds very quickly.”

One staff member told us following a person falling over in their home, they assessed the situation, contacted an ambulance, waited with the person, informed their manager, and completed an incident report.

Incident reports showed following incidents the registered manager reassured the person, spoke to their family and liaised with the relevant health professional.

However, record keeping was not in line with their safeguarding policy. For example, there were not clear records of staff training, incident records were not stored in a separate folder and there was no evidence staff had read the policies. The provider understood the improvements which were needed.

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.

There was evidence of the registered manager liaising with people and health professionals to maintain safe systems of care. For example, changing medication management processes to prevent administration errors.

For 1 person, recently discharged from hospital with more support needs, the registered manager had been fully involved to ease transition back home. They had liaised with the person and their relative to ensure the required support was in place.

Staff told us they were given clear and timely updates when someone’s needs had changed.

However, 1 care plan had not been fully updated following a change in the person’s needs and included conflicting information relating to mobility and skin care. The involvement of healthcare professionals was not clear in care plans. This meant there was a lack of evidence that peoples’ needs and risks were being managed appropriately.

The provider did not understand how to escalate concerns of abuse but did maintain a safeguarding log with basic information.

There had not been any incidents which the registered manager needed to report to outside organisations, such as the Care Quality Commission or the local authority safeguarding teams. However, staff lacked knowledge about safeguarding procedures, and how and when to refer concerns to the local authority safeguarding team. We found 1 staff member’s safeguarding and Mental Capacity Act (MCA) 2005 training was significantly out of date which meant staff were not continually refreshing their understanding.

Policies and procedures for managing safety events were not dated and included guidance which was not relevant for the service. For example, referring to service user to service user harm, and stating if there was an incident of abuse which involved the management within the service, then the incident must be passed to the next line manager. However, there was no next line manager within the service.

Staff knew how to monitor for signs of abuse and followed healthcare guidance to ensure people were safe. Staff gave examples of how they protected people’s rights and understood the principles of the MCA 2005. We did not identify signs of a closed culture or people at risk of harm. People felt safe with staff and empowered to raise concerns.

Following our feedback the provider took immediate steps to address the concerns.

The provider did not always evidence how they had worked with people to understand and manage risks. Records did not always demonstrate that staff were providing care to meet people’s needs.

The registered manager and staff demonstrated a good understanding of individuals’ needs and associated risks. However, care plans did not consistently provide sufficient evidence that risks had been formally assessed and were appropriately managed. For example, there was conflicting information regarding 1 person’s mobility needs, limited detail on the monitoring of equipment, and unclear documentation relating to input from the District Nurse. In addition, information outlining the management of risks to a person’s skin integrity lacked clarity and sufficient detail.

Daily records stated 1 person had communicated pain and discomfort on 2 occasions, however, there was no information about how staff had responded to this. When discussed with the registered manager they were fully aware of the cause of the pain and how it was managed but this was not reflected in the care plan or daily records.

However, people told us staff provided safe and supportive care that met their needs and enabled them to do the things that mattered to them.

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 risk assessments lacked important information, for example, information on fire risks. For 1 person the assessment was not fully completed or dated.

Training records for 1 staff member showed health and safety training, including moving and handling, was significantly out of date.

However, when asked about supporting people with equipment 1 staff member told us, “We use a hoist and sling for 1 person, I refer to my manual handling training and ensure the device is checked, the sling should be checked, if not it could put them at risk. [We are] supposed to check them visually before every use and check they have a service every 6 months and are up-to date with services and not use if anything is wrong or there is a risk.”

People told us carers maintained their environments and supported with domestic tasks when required.

Following our feedback, the registered manager advised they will work with a care providers association for support to put a more robust environmental risk assessment in place.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development.

Staff confirmed they had regular ‘check ins’ with management, and due to the registered manager attending a lot of care calls they were able to observe practice. However, there were no formal records of supervisions, staff meetings, audits or competency assessments/spot checks.

There was a lack of evidence to show that there were robust and safe recruitment practices in place. For example, missing staff references and gaps on application forms.

As previously stated, important, mandatory training was significantly out of date for 1 staff member.

One person told us that call times were previously delayed which had an impact on their day, however this was better now.

One relative told us “Timing of the care visits are good. They always stay for the planned duration of the visit and sometimes later if need be.”

Staff told us they had a good induction which involved training and shadowing experienced staff. They told us they had regular ‘check ins’ with other staff and the registered manager and updated each other constantly. They told us the manager was understanding and supportive.

Staff had no issues regarding the rotas. Staff said the registered manager frequently observed their practice.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns withappropriate agenciespromptly.

Peopletold us theirenvironmentwaskept cleanand that staff wore Personal Protective Equipment (PPE)whenrequired.

Staff had an awareness ofbestpracticeand guidance relating toinfection prevention and control.

Policieswerein place and in line with best practice guidance.

Medicines policies, procedures and systems did not follow current legislation, professional guidance and relevant best practice.

The provider did not have its own medication policy in place and the policy they were using did not reference people declining their medication, controlled medication, as required medication or homely remedies.

There was also a lack of evidence that staff were suitably skilled to administer medicines or that their competency had been assessed. There was no evidence of audits of medication management and care plans required updating to include new medication arrangements. The registered manager had recognised the need for additional medication administration records to be put in place following someone’s discharge from hospital which they were implementing.

All these issues were being addressed by the provider.

However, people expressed no concerns regarding the administration of their medicines and confirmed that staff supported them to receive their medication as prescribed and at the appropriate times. One person self-administered their medication and maintained full responsibility for its management. Staff were required to provide physical support at the person's direction.

Staff could talk through the important steps to take to ensure safe medication administration.

There was evidence of the registered manager liaising with the person, pharmacy and GP service to improve the medication administration system in place.