42 Beeston Drive

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

We assessed 7 quality statements in the safe key question and found areas of both good practice and concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Our rating for this key question has changed to requires improvement. Relatives told us people were safe and happy with the support staff provided to them. Risks relating to people were assessed and bespoke plans were developed to meet people’s care and social needs. However, we found improvements were needed in the detail of some people’s plans to ensure staff had enough information on how to provide safe care. The management team also needed to ensure that any restrictive practices were recorded and DoLS updated accordingly. Staff knew people well and were knowledgeable of people’s care and support requirements. Fire, health and safety and environment checks were completed. However, we found improvements were required. Checks hadn’t been recorded for a period of time and the inspector identified areas of the environment that required improvement. The nominated individual acted on this feedback as soon as it was raised. Systems were in place to record events that occurred, including events reported to the local authority and CQC. A provider policy was in place to guide the staff in these areas. However, we found one event had not been reviewed by the management team during our assessment. The nominated individual immediately took action to address this. Recruitment checks took place and staff completed training prior to providing care to people. Staff spoke positively about training received; this was also reflected in positive feedback from relatives. People’s care and support needs were assessed prior to moving into Beeston Drive. A relative spoke approvingly over their experience of the transition plan developed in this area when their loved one moved into Beeston Drive.

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.

Relatives felt involved in their loved one’s care. Staff kept them informed of any events that occurred and asked relatives for their input. Comments included, “Staff are really good. If there's anything wrong, they tell me, they do listen” and “If anything happens, they do get in touch.”

We received mixed feedback from staff over learning from events. Comments included, “Always had a de-brief as it can be quite beneficial” and “We would all get together and speak as a team and look at why something was happening.” However, other staff shared, “(This) could be improved as there has been no stable manager to coordinate this, which had been discussed at a recent team meeting as an area for further focus.” Staff provided an example of how they had collaboratively learned from past experiences, working closely with both the individual and their family to determine what strategies were effective and how to ensure a more consistent approach to care. They also described additional support that was implemented, noting that the individual is now "much happier." Staff also described a review with the provider’s positive behaviour team, of events that occur at the location to ensure training remains appropriate. This included a review of all significant events and specialised training bespoke for each person. They considered if these were still relevant. Staff commented, “The behaviour team would review and teach what you need to know. It should be person centred and they don’t teach techniques not required, only what we need to know.”

Systems were in place to ensure events which occurred were responded to in a timely manner. There was a policy in place which set out the expected procedures for the recording, reporting and analysis of accidents and incidents. Upon reviewing the records, we found that these processes were generally adhered to. Events which occurred were reviewed by the management team. This was completed in conjunction with the providers positive behaviour support lead to identify any lessons learnt. However, we found one recent incident record which had not yet been reviewed by the management team. We brought this to the attention of the nominated individual, who assured us that the matter would be reported to the local authority's safeguarding team and investigated.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us their loved ones were safe. We were told, “Generally, very happy with the placement.” Adding, “Care is fine, no problems.”

Staff told us they had received training in safeguarding and said they understood when and how to report any safeguarding concerns. Staff were also required to complete a safeguarding competency check on an annual basis. Staff told us they would feel able to report any concerns, and there was a file in the office of telephone numbers should they need them. One staff member described the signs of abuse and told us, “Any marks I would report.”

We observed positive interactions between staff and people, and noted people received appropriate care. During the assessment we observed some practices which could be identified as restrictive. We reviewed the reasons for such restrictions. Please refer to the process section of this quality statement.

Safeguarding policy and procedures were in place to support staff to effectively manage allegations of abuse and safeguarding concerns. We reviewed records and found any allegations of abuse had been appropriately reported and where appropriate, investigated. Detailed records were maintained. However, we shared with the nominated individual an incident record which managers had not reviewed. The nominated individual took immediate action, including reviewing the event and any initial lessons learned. Support plans did not consistently document the restrictions that were in place, which could potentially deprive individuals of their liberty. For example, one person's support plan did not mention the locks on their bedroom furniture. Another person's use of plastic cups for all drinks was not documented, and a bedroom monitor used to alert staff to epileptic seizure activity was not detailed in the support plan. While some of these decisions were historically made in the person’s best interest, not all practices had been formally recorded or reviewed. We could not be sure the least restrictive options had been identified. We raised this with the management team who told us they would undertake a review of people’s deprivation of liberty safeguards (DoLS) and associated support plans to ensure they reflect current practices to mitigate risk.

Relatives told us staff knew people and their support needs well and kept them involved. However, some raised concerns over the inconsistency of registered managers at Beeston Drive and changing of staffing. Comments included, “We really do work in partnership with them” and “[Staff] been with [Person] from the beginning. There have been some changes to staff, but thankfully it all works really well.” Another relative told us, “Staff keep us involved, keep us informed of things and appointments. Not so much in terms of care planning but keep us informed and ask us.” However, another shared, “The main concerns are communication. It's not as good as it was, there's been a lot of staff changes” and “The one thing is about having a consistent manager. I think they haven't had that.”

Staff told us they were given information to support people to manage risks through their care and positive behaviour support plans. This also included staff discussing people having a DoLS in place and aspects of risk management agreed in the person’s best interests. For instance, one person had a monitor installed in their bedroom due to a health risk, allowing staff to check on them without causing disturbance; appropriate documentation was completed to support this measure. Another individual had a restriction in place that limited their access to a certain area of the home without staff supervision, due to the potential risk of injury. In contrast, other residents were not restricted and could access this area independently. Staff told us they had supported people to take positive risks. They gave some examples where they had supported someone to attend an activity, even though they weren’t sure how it would turn out. They considered the initial support needed and had a contingency plan in place. They said the person “absolutely loved it” and they had continued to try new things. Another person was supported to go on holiday abroad for the first time. Staff took small steps to support the person to feel comfortable with aspects of the travelling and the person really enjoyed the holiday.

We observed various staff practices that clearly demonstrated an understanding of how to deliver safe care while effectively mitigating potential risks. For example, we observed staff intervene to offer appropriate support to a person when eating. This included ensuring that the person was utilising specialist crockery designed to support them with eating their meals. We observed staff supporting a person using their preferred communication methods, which assisted the person to communicate their needs.

Risk assessments and support plans were not always robust or detailed enough to guide staff in managing risk. We identified one care plan where some information was not reflective of the individual. Upon discussing this with staff, we learned that the information was about a different person. We shared our concerns with the nominated individual, who immediately took action to rectify this person’s care plan and risk assessments, acknowledging the care records were of another person. We found one person’s emergency guidance lacked detail for staff intervention in the event of a health emergency. We raised our concern with the nominated individual who immediately reviewed this and shared with staff. Where needed, people had detailed positive behaviour support plans. These are personalised plans developed to support people and those who work with them through periods of anxiety and distress. This was underpinned by a detailed provider policy. Staff received appropriate training to support people through periods of anxiety or distress. This training was delivered in line with best practice guidance. Regular face to face training by accredited trainers was provided.

Overall relatives were happy with the environment and people were safe living at Beeston Drive. We were told, “They [staff] support [person] really well, really happy. It's turned [persons] life around.”

The nominated individual acknowledged fire, health and safety checks had not been completely as routinely as needed. During the onsite assessment the management team responded to any concerns we raised regarding the environment. For example, we raised concern that a hallway carpet needed replacement. We received confirmation these were replaced following the end of the assessment.

Overall, the home was clean and maintained. There was a fitted kitchen and a nice garden. However, we identified several areas where improvements were required to ensure the environment was safe for people. For example. we observed one of the bedroom doors was catching on the carpet and not closing independently. As this was a fire door, it may not close effectively in the event of a fire, posing a potential safety risk. Another person’s bedroom was untidy with boxes and items on the floor. There was a small outside patio area outside of one person’s bedroom. We were told this was no longer used, but it was untidy with old chairs and an upturned swing which needed removing. We raised our concerns with the nominated individual who confirmed the maintenance person would address this the following day, along with maintenance to another door.

Systems were in place to maintain a safe living environment. However, the provider had failed to identify environmental concerns we raised during the assessment. Certificates were in place to demonstrate equipment was in full working order. Where systems to monitor fire checks and fire drills were in place, we identified that these were not completed for a number of months. We raised this issue with the management team, who acknowledged that this area had not previously been monitored. They demonstrated that new systems had recently been introduced to address such concerns and improve safety in this area.

Overall, relatives spoke approvingly over the care people received from staff. However, we received some feedback over changing of staff and inconsistency of management. Comments included, “Staff keep me up to date and keep in touch. It's mainly the key workers. The one thing managers, there's been a lot of managers over the period” and “I think they have good training, they involved me in the training when [person} first move in.” Another told us, “There’s been a lot of staff changes.” Adding, “Once they are trained; Excellent, wonderful in fact.”

Staff told us they received face to face induction training alongside online eLearning. Staff shadowed experienced staff prior to providing individual care to people. Comments included, “Before I started I had to go for SCIP (specialist training) training, we did autism and communication. We went and did 1 weeks' worth of training and had to do eLearning after this” and “I did induction training before I started working. I have 2 eLearning modules to do. I’m working towards the Care Certificate at the moment.” Another staff member told us the provider offered quite a lot of training, which would differ for the various roles. This included bespoke training if this was requested. Staff told us there had been a period of instability, due to management changes. There had been a staffing restructure and the provider had been recruiting for a registered manager. Staff said they felt better supported now there was a shift leader in post and the nominated individual was available to support if required.

During our site visit, staffing was in line with the description of commissioned hours. There was a staff member to support, with an additional member of staff for where additional staffing support was required.

Systems were in place to ensure staff were recruited safely, which was underpinned by a clear policy and procedure. Pre-employment checks had been carried out. The provider’s supervision policy indicated quarterly supervision (which included spot checks) should be undertaken. However, records did not always evidence supervision had been carried out in line with the policy. We identified several gaps in the staff matrix provided to us, including missing supervision dates and incomplete safeguarding competency checks that the provider was responsible for completing with staff. During the assessment, the management team shared a new template they were implementing to capture this information moving forward to make improvements in this area. Staff received the necessary training to perform their roles effectively. Some training was due for recompletion, which the management team had already identified and scheduled dates for.

Overall relatives were positive of the environment and people were happy living at Beeston Drive.

Staff were able to describe the cleaning routines within the home. Staff confirmed they had access to adequate supplies of personal protective equipment (PPE) such as gloves and aprons.

Some areas of the home required a deep clean or replacement furniture. For example, the sofa in the lounge and one person’s computer chair was worn. We raised both issues with the management team who took action to arrange for suitable replacements. The laundry was a very small area and required organising to maintain high hygiene standards. We observed that adequate stocks of PPE were available for use.

Systems were in place to maintain the living environment to a hygienic standard but checks of the environment had not been completed as routinely. This had led to some wear and not all furniture which needed to be replaced had been identified. When we raised this immediate actions were taken.

Relatives told us staff kept them updated about any planned reviews, and actively included involving them in supporting their loved ones. Comments included, “Medication, yeah. I get involved in everything. We really do work in partnership with them. When [person] was unwell, they kept me involved. There's a lot of consistency.”

Staff told us they received training, including specialist rescue medication training and had regular competency checks in relation to medication administration. A staff member said, “We do a 5-page competency, which covers everything. When first trained we have to pass it three times. Every year we do the same competency.” The provider was signed up to the principles of stopping over medication of people with a learning disability and autistic people (STOMP). Whilst a couple of staff were unfamiliar with the acronym, they described following the principles in practice. Where people were prescribed PRN (as required) medicines, staff were aware of the protocols to follow and other strategies. One staff member told us,” [Person] has a protocol and we do this first. “ Staff told us their training included actions to take if a medicines error occurred. We were told, “We have to fill in a form. We would let the manager or on- call know of any error and ring 111 for advice.”

A medication policy was in place, which had been reviewed and updated. People had person centred medication profiles in place. Staff had undertaken training and competency checks. Appropriate protocols were in place for certain “as required” medications and described following the principles of STOMP (Stopping the over medication of people with a learning disability, autism or both) . The protocols reviewed had been recently written, however no review date was added. We shared this with the nominated individual and consultant who agreed to amend these and ensure they were regularly reviewed. There was some inconsistency in staff signing for “as required” medicines. Was saw some examples where a code was recorded as “not required”, or staff had left the record blank. Staff needed further guidance and clarity. Staff had not always countersigned the medication records when they had handwritten an instruction for a medicine. Controlled drugs were stored in a separate locked box in a locked metal cabinet. When administered, staff had doubled signed these and a daily count was undertaken. However, a controlled drugs register was not in place in line with their policy. The nominated individual confirmed during the assessment that one had been provided. For medicines taken out of the building, there were count sheets recorded with “signed out" medicines, but no other documents showed staff had followed the policy around signing out medication. The nominated individual and consultant agreed to address this. Medication audits were undertaken, and a recent audit had identified some actions for improvement which were in progress. This included ensuring the fridge temperatures were consistently recorded and no gaps were left on the medication records. The nominated individual also ensured a tamper proof box was purchased for disposal of stock to be returned to the pharmacy.