Beckfield House Residential 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 inspection we rated this key question requires improvement. At this inspection 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.  At our last inspection the service was in breach of legal regulation in relation to the way people’s medicines were managed. Although there had been some improvements made, the service remained in breach of legal regulation in relation to the safe management of medicines.

This service scored 62 (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. The service held daily flash meetings discussing any safety concerns, feeding back to staff lessons that had been learnt during investigations. Staff felt the management team listened and acted when they raised concerns. People and their relatives told us that they knew who to go to should they have a concern and that they had faith concerns would be acted upon.

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.  People’s relatives told us the service worked with them prior to their relative coming into the service. Plans were in place to make sure people received the support they needed even when the admission was an emergency. Staff made sure to make referrals to other health care professionals including GP’s, speech and language and physio.

The service 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 recognise when people were at risk and therefore did not always protect their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. When concerns were identified they were share quickly and appropriately.  For example, despite staff being trained on how to keep people safe from abuse and neglect, during the inspection process the registered manager identified an occasion where staff had not identified a potential safeguarding situation. The registered manager acted quickly raising a safeguarding referral and talking to staff around recognising reportable situations. People and their relative we spoke to all told us they felt safe at the service.

The service mostly 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.  However, some people had health and social care needs that were not covered in their care plans. The registered manager recognised some care plans needed up dating and they were working with the management team to ensure this was done promptly. Staff at the service knew people well and worked closely with new staff and agency staff, there was also a summary of care board in the staff only area. However, there is a risk with information not being covered in the care plan that staff could be approaching the risk inconsistently and would not have the information needed to support people effectively. People and their relatives said that they were supported to manage risk, they were involved and their choices respected.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.  The service had a maintenance team who worked to maintain the environment. There were areas of the home that needed some refurbishment. This had been recognised by the registered manager. The service had a refurbishment plan in place to address this. Relatives told us the environment was well maintained.

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.  People and their relatives told us there was always enough staff including in the evenings and weekends. A relative said that they had noticed new staff were always buddied up with experienced staff. When reviewing accidents and incidents, they felt they needed additional staff in the afternoon, and they increased staffing levels accordingly. The service tried to cover sickness with their own staff including bank staff. Where needed they used agency staff, requesting staff that had worked at the service before. The service had staff to support with activities within the home. These staff were also trained in care and were able to support at mealtimes and when needed.

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.  The service had systems and processes in place that were effectively used to ensure the home was kept clean. Such as cleaning schedules and environmental audits. People and their relatives told us the service was always clean, and rooms regularly received a deep clean. We saw housekeeping staff cleaning people’s rooms during lunchtime, so they were not disturbing people when they were in their room.

The service did not make sure that all medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning.  At the last inspection we found people did not have protocols in place for “As and when required medicines” (PRN). At this inspection we found PRN protocols were in place. However, they did not give the staff clear guidance on what signs and symptoms individuals would show which would mean they would need to be given specific PRN medicines. The registered manager acted following feedback to update the PRN protocols. A person at the service was receiving their medicines either in liquid form or tablets which were crushable. The service did not have a protocol for staff to follow when administering these medicines which had led to staff administering medicines unsafely. Following feedback, the registered manager sought advice of a pharmacist and updated the protocol for these medicines to ensure medicines would be administered safely. The mental health team had advised that a person could be given their medicines covertly. The service had not followed the principals of the Mental Capacity Act 2005 (MCA) in regard to giving medicines covertly. The service had not completed a capacity assessment, to determine if the person had capacity to make this decision themselves, additionally there was no evidence that a best interest decision had been made.