Beulah Road

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 changed to good. This meant people were now safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People were encouraged and supported to raise safety concerns with the provider. The registered manager and staff understood the importance of reporting safety concerns and learning lessons when things went wrong.

Systems were in place to support staff to report and record safety concerns and events when they arose. The registered manager investigated safety concerns and events and used the learning from these to support staff to continually improve their practice, reduce risk and keep people safe.

The service 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.

Information was obtained from people, and others involved in their care, about people’s individual needs and risks they might face. This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care and support from the moment they moved into the care home.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

At our last inspection, staff did not know how to report abuse and were not able to articulate how they would spot signs if people were at risk of abuse or harm and had not received up to date safeguarding training. This had placed people at risk of harm and was a breach of regulations.

At this inspection, we found the provider had made enough improvements to ensure people were protected and kept safe. This meant the service was no longer in breach of regulations.

The registered manager and staff now understood how to safeguard people. They had all received up to date safeguarding adults training and knew how to recognise and report abuse. The registered manager and staff were able to articulate how they would spot signs if people were at risk of abuse or harm. A member of staff told us, “Abuse of any kind is not tolerated in this care home. The people we support are vulnerable and I would not hesitate to tell my manager [registered] straight away if I saw anyone being abused or neglected here.”

People told us they felt safe living at the care home. One person said, “I feel very safe living here with the staff who know how to look after me.” Another person added, “I do feel safe living here and that’s probably the best thing I can say about the home. I’ve got my own flat in the garden and the staff are always popping in to see how I’m doing.” Feedback we received from external care professionals was equally positive. One said, “My clients are safe and comfortable in the care home. Staff are caring and always act in their best interests.”

The registered manager worked proactively with the relevant external health and social care professionals and bodies, including the local authority when a concern was raised and took appropriate action to safeguard people from further risk when this was required. The registered manager told us, “I have unfortunately witnessed some poor staff practice in the care home. I did not hesitate to immediately suspend the staff involved and report the incident straight away to the local authority, the CQC and my line manager.”

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last inspection, the risks people might face were not always accurately assessed, monitored or managed. This had placed people at risk of avoidable harm and represented a breach of regulations.

At this inspection we found the provider had made enough improvements to ensure staff understood and managed identified risks well. This meant the service was no longer in breach of regulations.

People’s care records now contained up to date and accurate information for staff to follow and help them keep people safe. For example, positive behavioural support, diabetes and epilepsy risk assessments and support plans had been developed with input from the relevant external health and social care professionals. This meant staff had access to all the essential information they needed to prevent or manage these risks. Staff were fully aware of the potential risks people might face and the steps they needed to take to prevent or safely manage them. A member of staff told us, “We have personalised plans in place which tell us exactly what action we need to take to safely support people with all their assessed needs.” Feedback we received from external care professionals was equally positive. One said, “Staff in the care home know each of my client’s needs and how to keep them safe from avoidable harm.” Another added, “Staff are aware of the health care needs of each of my clients and seek advice from the doctor or other relevant health care professional as and when required.”

Care plans were person-centred and showed evidence of staff’s positive approach to risk-taking. For example, one person had a self-contained flat with its own adapted facilities within the grounds of the care home where they lived semi independently and took positive risks, such as cooking their own meals without any staff support, which enabled them to develop their independence.

Systems were in place to ensure risks to people were continually assessed, monitored and reviewed. People moved freely around the care home and spent their time as they wished, with no unnecessary restrictions. Care plans showed evidence of staff’s positive approach to risk-taking.

The service detected and controlled potential risks in the care environment. They made sure equipment, and facilities supported the delivery of safe care.

The premises were kept free of obstacles and hazards which enabled people to move safely around the care home. The physical environment had a well-equipped and suitably adapted sensory room that was extensively used to meet the sensory needs of the people living there. All the care homes doors which lead outside had been suitably adapted with ramps and grab rails to enable people to safely access the rear garden or wider community. An external care professional told us, “The care home is a comfortable environment for people to live.”

There were effective arrangements in place to monitor the safety and upkeep of the premises. Regular checks were completed to help ensure the safety of the home’s physical environment and fire safety equipment. Staff told us they had clear guidelines available to help them deal with emergencies. In relation to fire safety, we saw emergency evacuation plans were in place to help staff evacuate people in an emergency.

Maintenance records demonstrated the environment was maintained to a safe standard. For example, regular visual checks were completed to check window restrictors, radiator covers, and fire-resistant doors remained safe and fit for purpose.

The service 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. However, they did not always ensure staff received regular appraisals of their overall work performance.

At our last inspection staff training and competency assessments were not being refreshed and updated at regular enough intervals. This placed people at risk and represented a breach of regulations.

At this inspection we found the provider had made enough improvements to ensure staffs training and competency-based assessments remained relevant and up to date. This meant the service was no longer in breach of regulations.

At our last inspection we found staff had not always received up to date training in learning disability and autism awareness, positive behavioural support, safeguarding, safe management of medicines, infection prevention, fire safety and first aid. At this inspection, we found staff now received all the relevant training they required to meet the needs of the people who lived at the care home through a mixture of e-learning and in-person practical and theoretical training and competency-based assessments. This training and competency-based assessments were also being routinely refreshed and updated. Several staff confirmed their training was being constantly refreshed. One said, “Our training is regularly updated, and the managers often assess us to see if we can do our jobs safely. I only recently had my safeguarding, fire safety and moving and handling training refreshed, and my competency to continue managing medicines safely reassessed by the homes manager [registered].”

At our last inspection we found the service was heavily reliant on agency staff who might not be so familiar with the needs, wishes and daily routines of people living in the care home. At this inspection we found the provider had no care staff vacancies and was therefore no longer reliant on any agency staff to cover staff shortfalls. The registered manager and several staff confirmed this. One member of staff told us, “We don’t use any agency staff here whatsoever, which must be a good thing right! Us permanent staff know what everyone who lives here needs and what their preferences are. It doesn’t matter how good an agency member of staff you might be they just don’t know the people who live here as well as we do.” The registered manager also told us since our last inspection one person was now able to access more social activities they enjoyed doing in the wider community because they used additional staff to support this person whilst they were accessing the local community.

However, contrary to the providers staff appraisal policy less than half the staff who worked at the care home had had their overall work performance appraisal by the registered manager in the last 12 months. We discussed this failure with the registered manager at the time of our inspection. They acknowledged the issue and assured us an improvement plan was already in place for the rest of the staff team to have their work performance appraised by the end of 2025.

Staff continued to have ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might need. Staff had regular individual and group meetings with their fellow peers and line managers. Several staff told us they had regular individual and group supervision meetings with the registered manager. One member of staff said, “We have regular supervision meetings with the manager [registered] who is always supportive and approachable.”

Staffing levels matched the staff duty rota on the day of our site visit. Care staff were visibly present throughout the service during this inspection and were quick to respond to people’s questions and requests for support. People told us the care home was adequately staffed. One person said, “There’s always staff about during the day and at night, so you know they are there if you need them.” An external care professional added, “I regularly visit and see there are enough staff working in the care home. I have noticed the staff are often quite engaged with my clients.”

Since our last inspection, staffing levels had been increased to ensure additional one-to-one staffing was now available to support one person living in the care home. This meant this individual could now attend more social activities they enjoyed participating in within the wider community as part of their positive behavioural support plan which had significantly reduced the number of incidents they had been involved in.

The provider continued to operate safe recruitment practices and only fit and suitable staff were employed to work at the care home. Staff files contained evidence of robust recruitment checks including application forms where gaps in employment were explored, professional and personal references, right to work and identity checks. The provider maintained a recruitment tracker to monitor staff recruitment and completed Disclosure and Barring Service (DBS) checks. This helps employers make safer recruitment decisions by processing requests for criminal record checks.

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

At our last inspection people living in the care home and staff working there were not always protected from the risk of infections because personalised and up to date COVID-19 risk assessments and management plans were not in place. In addition, some items of food stored in the care homes kitchen which had been opened were not always correctly labelled contrary to recognised basic food hygiene practices. This had placed people at risk of harm and represented a breach of regulations.

At this inspection we found the provider had made enough improvements to ensure people were protected from the potential risk of infection and poisoning from contaminated/out of date food.

The registered manager and staff understood how to prevent and control infection and had access to enough resources and equipment to help them reduce the risk of infections spreading in the care home. Staff had received up to date infection control training. The registered manager and staff also knew about basic food hygiene practices and had received up to date food hygiene training. All opened items of food were appropriately stored in the kitchen fridge and were correctly labelled and within their use/consume by date in accordance with basic food hygiene standards. The care home had been awarded a ‘Very Good’ rating [The highest rating] from the Food Standards Agency for their food hygiene practices.

The provider’s infection prevention, control, and food hygiene policies and procedures were current and reflected national guidance.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happenedcapacities and preferences.

Medicines systems were well-organised and safely managed. Since our last inspection, the provider had improved how medicines were managed. For example, following a medicines review with one person living in the care home and all the relevant health and social care professionals less restrict alternative interventions are now used to help staff minimise the risk of incidents of distress involving this individual happening. This person is no longer prescribed any psychotropic behavioural modification medicines in accordance with recognised best medicine practice and the national NHS England project STOMP [Stopping the Over Medication of People with a learning disabilities autistic people]. In addition, although no one living in the care home was willing and capable of safely self-medicating their prescribed medicines were kept securely in locked cabinets located in each of their bedrooms. This approach was person-centred, respected people’s privacy and dignity and minimised the risk of medicines being administered to the wrong person.

Medicines stocks, balances and records showed people consistently received their prescribed medicines as and when they should. People told us staff supported them to take their medicines as they were prescribed. An external care professional told us, “Staff make sure people are being given their medicines according to their prescription, as and when required.”

Care plans included detailed guidance for staff about how people needed and preferred their medicines to be administered. This included detailed protocols in relation to 'as required' medicines which meant staff had access to clear instructions about when and how to safely administer these types of medicines. Staff received relevant training and their competency to continue managing medicines safely was routinely assessed. This helped staff remain clear about their roles and responsibilities in relation to the safe management and administration of medicines. There were regular audits of medicines at the service. This included regular checks of staff’s practice to ensure they remained competent to administer and manage peoples prescribed medicines safely.