The Beaufort Care Home

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 remained 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 41 (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.

The provider did not have effective processes in place to identify trends and learn from incidents. Whilst there were analysis of falls, infections, and pressure ulcers. Other incidents such as those resulting from behaviours of distress were not adequately reported or recorded and therefore could not be analysed.

Lessons had not been learned from previous inspection such as issues in relation to auditing and quality assurance systems.

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.

Staff used a hospital transfer pack whenever a person needed to be admitted to hospital. Staff printed the pack as required, and it contained key information about the person, including a summary of their care and support needs, to support continuity of care during the transfer.

Staff and the registered manager worked closely with health and social care professionals to ensure people had access to joined up care. The GP visited weekly to conduct a ward round with the registered manger.

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. The provider did not always share concerns quickly and appropriately.

Relatives did not always feel their loved one was safe. Whilst one relative told us, “I feel [name] is safe there, not in any danger” another relative told us, “I wouldn’t say [name] is particularly safe. Most staff are lovely, but they are always short staffed.” Another relative expressed concern about their loved one’s safety through the night due to staffing levels.

Staff did not always recognise, escalate or manage concerns appropriately. We identified incidents involving potential harm where staff had not appropriately escalated concerns, and records did not demonstrate effective management review, oversight or follow-up actions. For example, a staff member documented that a resident had thrown a cup of tea at them. This was not reported, flagged as an incident, or followed up in any way.

Staff understood their responsibility to keep people safe and had received safeguarding training. One staff member told us, “I observe for signs of abuse. This can be from anyone, carers, family members or professionals. It is my duty to raise these concerns.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that appropriate legal authorisations had been sought in relation to any restrictions imposed on people. The registered manager understood their responsibility to ensure that any restriction on a resident's liberty is necessary, proportionate, and lawfully authorised.

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.

Care records did not provide staff with adequate information to support safe moving and handling practices. Some care plans contained guidance that was not in line with accepted moving and handling principles and could place people at risk of injury. In addition, care plans lacked sufficient detail to guide staff on how to safely support individuals with moving and handling tasks. Important information about the level of support required, for safe transfer techniques, and use of equipment was either limited or absent.

Incidents and behaviours were not consistently recorded, monitored, or analysed, meaning patterns and triggers could not be effectively identified. This limited staff's ability to implement proactive strategies to reduce risk and support people safely.

Several care plans we reviewed contained identified risks; however, corresponding risk assessments had not always been completed. This meant there was insufficient guidance available to staff on how to safely manage known risks and ensure consistent care.

These findings demonstrated that the provider did not consistently assess, document, monitor and manage risks effectively. As a result, the provider could not demonstrate that people were consistently protected from identified risks or that safe care and support were always delivered.

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.

During the inspection, we observed a hoist charging in a corridor close to a designated fire escape. This practice was contrary to the recommendations contained within the provider's external fire risk assessment. The presence of equipment charging within an escape route could obstruct evacuation and increase risks in the event of a fire. In addition, information used to support emergency evacuations, such as people’s Personal Emergency Evacuation Plans (PEEPs), was not up to date. We found lists contained the names of people who no longer lived at the home and did not include some people who had recently moved in. This meant staff and emergency services, such as the fire service, may not have had immediate access to accurate information about who was living in the service and the support they would require during an evacuation.

We identified out-of-date food stored within the service. The provider had not ensured effective systems were in place to monitor food stock and remove items that had exceeded their use-by or expiry dates. This placed people at risk of consuming food that may no longer be safe. These concerns were shared with the management team, who provided assurances that a comprehensive kitchen audit would be undertaken and that immediate action would be taken to address the issue. However, during a subsequent site visit, further out-of-date food was found within the service.

These findings demonstrated that the provider had not maintained effective oversight of fire safety, emergency preparedness and food safety. Identified risks had not been consistently recognised, monitored or addressed, and actions taken had not been fully effective in preventing recurrence. As a result, the provider could not demonstrate that people were consistently protected from avoidable risks to their health, safety and wellbeing.

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.

People told us they did not feel staffing levels were sufficient. One person told us, “Staff are very busy and there are not enough staff.” Another person explained they have to wait at times when they press the buzzer as staff are busy. Relatives shared the same view. One relative told us, “The biggest problem is definitely the staffing levels. You can't even get in or out of the building for ages, especially at weekends. There’s just not enough staff around,” another said, “Staff wise they are a little bit short. More so on the care side. Especially at weekends. They always seem to be rushing from one person to another. If we ask for assistance, it is never immediate.”

Staff gave mixed feedback regarding staffing levels. Some staff members felt there were enough staff on duty to meet people's needs. However, others felt staffing could be stretched at busy times, particularly when supporting people with higher levels of dependency which could limit opportunities for staff to spend meaningful time with people beyond providing essential care. Some staff suggested that additional support, such as an extra care worker or a floating member of staff, would help improve the service and reduce pressure on the team.

We reviewed the service’s dependency tool and found it was not being used effectively. Some individuals’ care needs had not been scored accurately, resulting in an underestimation of the staffing hours required and giving an inaccurate picture of the service’s staffing needs.

Staff had been recruited safely in line with the provider’s policy and best practice guidance.

These findings demonstrated that the provider had not consistently ensured sufficient numbers of suitably skilled, competent and effectively deployed staff to meet people’s assessed needs. The provider did not always use dependency assessments effectively to determine staffing requirements, which meant staffing levels may not have reflected the level of support people required. Feedback from people, relatives and staff indicated that staffing pressures affected the responsiveness of care and staff availability. As a result, the provider could not demonstrate that staffing arrangements consistently supported the delivery of safe, effective and person-centred care.

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.

Infection prevention and control systems were not always effective. We found the kitchen was not maintained to an appropriate standard of cleanliness, creating a risk of cross-contamination and potential illness for people using the service. These issues had not been identified through the provider's auditing processes, as a recent audit we reviewed had rated the kitchen as clean and tidy.

We observed a resident's bed had been remade using soiled, stained bedding. This increased the risk of the spread of infection and did not promote people's comfort or dignity. In addition, clinical waste bins were not available in bathrooms, which meant staff did not always have appropriate facilities to safely dispose of clinical waste.

However, staff had received infection control training, and we observed staff wearing PPE which was readily available throughout the building.

These findings demonstrated that the provider had not consistently implemented effective infection prevention and control measures. The provider had not ensured that all areas of the service were maintained in a clean and hygienic condition, and staff did not always follow safe infection control practices. In addition, governance and auditing systems had not been effective in identifying and addressing these concerns. As a result, the provider could not demonstrate that people were consistently protected from the risk of infection and cross-contamination.

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

Topical medicines were not always stored safely. During the inspection, we found prescribed creams had been left unattended and in plain sight within people's rooms, despite risk assessments specifically stating that these medicines should be stored out of sight.

The provider did not always ensure staff had the information they needed to safely monitor people’s prescribed high-risk medicines. For example, one person’s care record did not contain guidance about potential side effects, adverse reactions, or the signs and symptoms staff should monitor, despite the person being prescribed and administered a high-risk medication.

People’s medication was administered as prescribed. One person told us, “Staff always give me my medication on time.”