Beechdale House 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

We identified 3 breaches of the legal regulations. Safety risks to people were not managed effectively. Managers had not robustly assessed and reviewed safety risks to people and made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were insufficient staff to support people with their identified needs. Staffing levels were not always consistent to meet people's needs and ensure safety. Staff were not deployed effectively across the service. Concerns were raised by people and their relatives about the lack of staff available at nights to assist in the safe evacuation of people in the event of an emergency or where people required assistance with moving and handling. Staff had not received all relevant training to meet the range of people’s needs at the service. Managers had failed to ensure a robust recruitment process was undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice. People and those important to them were supported to understand safeguarding and how to raise concerns when they didn’t feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

While one relative gave negative feedback regarding a previous incident where their family member had sustained an injury whilst being moved by staff with the use of a hoist, the majority of people gave feedback they felt safe with staff. Relatives told us they had confidence in the staff who were supporting their family members. One person told us, “‘I feel safe, it’s very important to me.” While another told us how they ‘felt safe’ with staff.

We discussed the previous safeguarding incident regarding poor manual handling, where a person had experienced harm following the use of a hoist. The registered manager explained the staff team had all completed manual handling refresher training following this.

We observed poor manual handling experiences with the use of a hoist for some people. Staff did not provide explanations for people who may experience challenges with understanding what was happening. People were left suspended in the air with no conversation around the procedure or attempt from staff to calm them. We saw one person exhibiting distress during this process. Staff were task focused and not providing appropriate person centred care. This left people at risk of harm.

Processes in place were not robust enough to ensure people were supported safely. We raised our concerns with the provider and registered manager. Although staff had recently been trained in manual handling, we saw staff were not following correct process and policy. The provider and registered manager advised they would provide refresher training and updates for staff.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some people and relatives we spoke with had concerns about the use of their call bell; either long times for a staff response or people trying not to use theirs during peak periods of personal care to avoid long waits. This left people at risk of harm and was a failure to provide person centred care. One person told us, “I have a crash mat, and wall alarm, if I need something I normally have to shout for attention in the evenings or at midnight.” Another person told us, “When staff say they will see me in a while, they are very busy and it’s not often a few minutes because they are busy- staff took half an hour to an hour to respond after saying they would only be a few minutes.” Another relative expressed their concerns regarding night staffing, they told us, “They don’t have enough staff at night. When my family member had an accident there were only three staff on shift.” Another relative we spoke with was more positive, and told us, “‘Oh yes, we are never waiting. I’ve been on several occasions when my family member has wanted assistance to go to the toilet.” There were insufficient staff on duty in the event of an emergency. The personal emergency evacuation plans (PEEP's) which are used to describe the actions staff should take to support service users in the event of an emergency showed the provider did not have enough staff present to support the emergency evacuation of people from the building. The fire plan showed staff are required to egress the building via a horizontal/vertical evacuation process and had identified specific people as being at high or very high risk during this process. The provider and registered manager had failed to ensure sufficient staff were available to ensure people were supported in the event of an emergency. The documentation in people’s care plans was incorrectly risk rated, which left people at further risk of harm.

We raised our concerns with the registered manager and provider regarding the low numbers of staff on the rota at night and the impact of this in relation to the effective evacuation of people in the event of an emergency. The provider agreed to review and increase their night staffing and review and amend the personal emergency evacuation plans. We could not be assured that this would prevent future risk of harm for people. We shared our concerns following our site visit with Nottinghamshire Fire and Rescue Service.

On our arrival at the service, the nurse in charge was unsure of the correct number of people residing at Beechdale House. This left people at risk of harm in the event of an emergency. We observed multiple occasions during our site visit where people had to wait for assistance from staff in communal spaces when they required this. One person indicated they needed assistance with their toileting needs. This person experienced a wait of 18 minutes once we raised this with staff. This left the person at risk of harm and was undignified.

We found staff had not always been safely recruited with appropriate references and a full exploration of their previous employment in place prior to their appointment. Interview questions were not detailed or sufficient to understand the motivation for a member of staff who lacked experience in the sector, wishing to work with vulnerable adults. This meant the registered manager could not be assured people were protected from the risk of potential abuse from unsafe staff.

Some people and relatives we spoke with raised concerns around the cleanliness of the service and their personal rooms. One relative told us, “They had entered their family members bedroom that day and could smell urine.” We checked this bedroom and confirmed the relatives’ feedback to be correct. While another relative expressed concerns about a sensor mat under their family member's bed which had not been cleaned. We checked and found this sensor mat to be in an unclean condition. We raised these concerns with the provider and registered manager. These shortfalls in infection prevention and control practice left people at risk and had not been identified in the audits of the daily cleaning records.

The provider and registered manager acknowledged the infection prevention and control shortfalls found at our inspection and provided a subsequent action plan for improvement and monitoring. We could not be assured this would be embedded moving forward. We shared our concerns with the local Infection Prevention and Control Team following our site visit for their ongoing quality monitoring of the service.

People were not protected from the risk of infection as staff were not always following safe infection prevention and control practices. Infection prevention and control practices within the service were not effective or robust, which left people at risk of harm. We found significant areas of concern in relation to poor infection control practice at the service, placing people, relatives, staff and visitors to the service at risk of exposure to infection. A number of the rooms we observed were significantly unhygienic, with broken furniture which was not secured correctly to the wall as required under Health and Safety Executive (HSE) guidance. In these rooms we also found poorly maintained personal sanitary support equipment, such as commodes. Areas of the home were in a state of disrepair meaning it could not be cleaned effectively. The home was visibly dirty in parts, with stains and malodour observed on some mattresses, bedding, flooring and furniture. The registered manager advised they had completed a full audit of the mattresses and bedding following our inspection and arranged replacements, but these shortfalls had not been identified prior to our inspection. This placed people at risk of harm from infection. We found pressure relieving equipment which were worn, soiled and not marked for specific people's use throughout the service. The provider audits had failed to identify these as a risk to people. Sink taps throughout the building had a build-up of limescale, which created an environment for Legionella and other water-borne pathogens to accumulate. This placed all people and staff at risk of harm. Window restrictors were either missing or ineffective and chemicals which were hazardous to the health of people we not safely stored. The provider responded to the concerns we raised following our inspection, but we could not be assured this would be embedded going forward.

The provider and registered manager had failed to identify the infection prevention and control and environmental concerns found at our site visit. Audits and daily walk rounds had not identified the shortfalls found and were ineffective. There was no overall service improvement plan in place to enable tracking of the required improvement measures and to allocate work to specific staff or teams. This left people at risk of harm. We shared our concerns found following the assessment visit with the local Infection Prevention and Control Team.

People told us they felt staff managed their medicines safely. However, our assessment found medicines were not managed safely and this placed people at risk of harm. People were not always fully informed of what tablets they were taking. A person we spoke told us, “I just get medicine, they put in my hand they keep an eye on me, I take seven at a go.” We observed the morning medicine round and found staff did not inform people of the type of medicines they were administering. We found staff did not always administer medicines safely, we observed the morning medicine round and observed staff to wear a red tabard with the words, ‘do not disturb’ written on the front. We observed staff interrupting staff administering medicines on several occasions whilst they were administrating medicines, the staff member engaged in conversation and did not ask staff to not interrupt. On one occasion they spoke at length whilst another staff member lent on the trolley. People told us staff gave them their medicines when they needed them.

Staff told us they completed training and had their competency assessed. However, we found this training was not always effective. For example, staff did not administer medicines in line with best practice guidance as detailed within this report. Staff we spoke with told us, they completed audits to ensure the safe management of medicines, however we found these audits to be ineffective. The registered manager did not have effective oversight of medicines which placed people at risk of receiving their medicines unsafely. Staff did not ensure medicines were stored safely and securely. For example, we found staff did not always ensure medicines and documentation relating to medicines and containing sensitive personal information to be left on several occasions. This placed people at an increased risk of harm.

Processes in place meant medicines were not always managed safely, this placed people at risk of harm. Audits had been completed but none of the issues identified had been picked up. For example, we found missing protocols for 'as and when required' medicines. These included medicines such as Lorazepam and other medicines used to reduce anxiety and pain. This meant staff did not always have information to instruct when medicines should be given. Protocols in place lacked detail and did not clearly direct staff when to give these medicines. For example, a person who had a protocol in place for co-codamol did not have any instructions to staff to ensure no other paracetamol products should be given alongside this medicine. People were at risk of receiving their medicines unsafely, as one covert plan we looked at was almost shredded and could not be read clearly. We found the medicine front sheet did not contain any information regarding how best to support the person to take their medicines in the least restrictive way. An external audit completed by the commissioners identified issues, an action was developed, which were documented to be rectified by the registered manager, such as PRN protocols and covert medicine plans. We found these were not rectified and the issues remained. This was a missed opportunity to improve the safety of medicines at the service. Prescribed medicines were found not to be stored safely. There was no recording of temperatures in the kitchen, so it was unknown if it was a safe environment for these to be stored. The trolley was accessible in communal areas and the kitchen was open for staff and service users to access. Transdermal patches were not administered in line with best practice guidance. Whilst there were specific charts in place these were not completed correctly, and staff did not know where on a person’s body these had been administered. All of these issues placed people at risk of harm.