Beauchamp Court

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

People received safe care and treatment from staff who understood their healthcare needs and followed healthcare guidance from professionals. Staff knew how to safely support people around their individual risks. Staff knew people’s needs and ensured people were involved in managing their individual risk and could access safe support when needed. When people’s needs changed or lessons learnt were identified from incidents and accidents, staff took action to protect them from avoidable harm. Staff received ongoing training and support. Staff knew how to raise concerns when needed. Medicines were managed safely. The home was safe and clean.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they felt safe in the home and with the staff that supported them. We saw examples of correspondence where staff had noticed changes to people’s needs, the registered manager had made a referral and updated the person’s relative in a timely way. This showed a joined up approach to ensure all areas of a person’s care had been addressed.

The registered manager showed us how they learnt from falls and accidents and incidents. They said “We are keen to learn from every fall or accident to ensure we see any patterns and can address them quickly.” Staff also told us how the registered manager shared any lessons learned with them through various correspondence such as handovers.

There was a clear system and policy in place to ensure staff knew how to report any concerns for safety or change to a person’s needs, the registered manager or senior staff could then analyse and take action in response to any accidents or incidents. All staff knew how to complete reports, take initial action. All reports were reviewed, further action taken and signed off by the registered manager. Lessons learned were clearly documented and discussed in handovers and staff meetings.

People and relatives told us how staff and the registered manager supported them to follow up on any treatment plans they had previously been given by health professionals. For example, when people moved to the home from a stay in hospital staff supported them in a safe way addressing their health needs and as a result people’s health had improved.

The registered manager and staff told us how they worked well with other health and social care services to ensure people received timely care and all information was shared with professionals. For example, when people had specific health needs, medical advice was sought to ensure staff knew how to support people safely.

We saw evidence of positive feedback from partners that had worked with the home. A professional said, “Staff are quick to contact me if they need any advice and are competent in following all instructions I provide. They are also good at sending updates if I require them.”

There were policies and procedures in place to support staff to understand when to refer people to other health and social care services and we saw examples of where this had been completed in a timely way.

People and their relatives told us they felt safe living at the home and the staff supported them in a safe way. One person said, “I have always felt very safe here. The staff keep us safe and the building is very secure.” Relatives told us, “The home is incredibly safe and the staff are amazing at ensuring [person] is safe at all times.”; “I have never had any concerns about safety. I always know [person] is in the best hands.”

Staff that were spoken to were knowledgeable in how to report concerns and were confident action would be taken quickly to ensure people remained safe in the home. One staff said, “(I would?) Tell the manager and make sure to record everything including times, witnesses, and who is involved. I have never witnessed anything. I make sure the right channels are completed – not that I have any worries about my manager he’s brilliant.”

We saw staff supported people safely and we saw regular engagement between staff and people to ensure people were safe and well.

There were clear policies and procedures in place relating to safeguarding and whistleblowing which offered staff advice and guidance in what action was required. Safeguarding training was provided to all staff. We saw evidence of safeguarding concerns being recorded, reported and investigated. We saw evidence of the registered manager working with the local authority to ensure they shared all relevant information to support people being kept safe from harm.

People received safe care and treatment managing their risks. One person said, “They know everything about me, the staff are very good here.” People’s relatives we spoke with told us how staff knew people’s individual risks. For example, around anxiety and how staff supported them well and knew the best way to ensure the person was happy as frequently as possible.

Staff knew people’s needs and individual risks and provided safe care. One staff member said, “I know everyone well, they all have individual risks that we as staff need to be aware of and make sure we follow the risk assessments to keep people safe.”

We saw staff supporting people in a safe way. For example, staff ensured people were supported appropriately if they had mobility needs. We also saw staff ensure people had support in line with their needs at meal times, this included staff sitting with people and cutting food up for people. We saw staff support people without rushing them and took their time to ensure people felt comfortable.

Individual risks were documented in people’s personal care plans. Risk assessments offered advice and guidance for staff to follow to ensure people received safe care. For example, risks around choking, mobility and falls were assessed and monitored.

People and relatives told us the home environment was safe. A relative told us, “The home is a bit run down – needs a revamp but not worried about Infection Prevention Control (IPC). The staff work really hard to ensure the home is clean and safe.”

Staff were knowledgeable in what their responsibilities were in relation to ensuring a safe home environment for people. One staff member said, “We have all received training in what to do to ensure everyone is safe in the event of a fire. I would locate the reason for alarm and delegate staff to get people to a safe area. I would be in charge of calling the fire brigade because I am the fire marshal.”

The home was safe and met people’s needs. Where people had additional mobility needs there were additional aids and there were clear, safe fire safety regulations being followed, such as fire extinguishers and emergency slide sheets.

Health and safety checks were completed regularly at the home. The care equipment was appropriately managed and technology was used safely in the home.

People and their relatives told us there were enough staff to meet their needs. One person said, “Staff are never in a rush, they always take their time.” Relatives also told us that there were always enough staff, “They never rush and always take the time to explain what they are doing.”; and “Staff really do know what they are doing and they take their time.”

Staff told us there were always enough staff and they were able to meet people’s needs as well as take their time to speak to people. One staff member said, “We have so many staff here, we always cover for each other (when staff absence occurs).” Staff training was completed regularly and staff felt the training programme equipped them well for their role as care staff. One staff member said, “Training is good here. We do training packages all the time and the refreshers are really helpful. I feel it helps me do my job to the best of my ability. If I wanted anything extra I could just ask and it would be booked.”

We saw there were enough staff to support people throughout the day. Staff supported people without them having to wait. Staff showed good knowledge and competency when supporting people, for example those living with mobility issues.

The registered manager ensured the dependency tool was regularly reviewed and updated when people moved into the home. This ensured there was always adequate numbers of staff to meet people’s needs. There was a clear training matrix which supported the registered manager to have oversight of what staff required refresher training and to ensure all staff remained well-trained and knowledgeable in their roles.

People and their relatives told us the home was clean and staff followed good infection prevention and control practice. One person said, “Staff are always wearing gloves and aprons when they need to and always keep the place very clean.” One relative said, ““It’s always clean and there is never an odour when you walk in.”

Staff were aware and followed good infection and prevention control practise. Staff received regular training and always had access to personal protective equipment. One staff member said, “We’ve never run out of supplies, there are always enough and the home is kept clean and tidy for people by the housekeeper.”

We observed the home to be clean and tidy. However, some areas required updating there was a plan in place for improvements to be made to the general décor of the home. There were no malodours and all areas of the home were seen to be hygienic.

There were policies and procedures for staff to follow around infection control. Audits were completed and action taken when needed. Staff received regular training in infection control and risk assessments were in place with advice and guidance for staff to refer to if required.

People and their relatives told us they received their medicines safely and were supported by competent staff. One person told us, “I always get my medicine on time in the morning and the evening.” A relative told us, “The staff are really good and always arranging reviews of the medication and referrals when needed. They have just been brilliant and always keep me informed.”

At the time of the on-site assessment the registered manager had not identified the concerns we found in relation to the management of medicines in the home. However, the registered manager took quick action in response to our concerns and we saw examples of thoughtful updates sent to CQC for the two month period after the on-site assessment. Staff were knowledgeable, competent and felt confident to support people with their medicines. One staff member said, “I do Medicines as one of the team leaders. We have competency tests and I feel confident when I do it.” The registered manager was in the process of implementing an online system, however, during our inspection this was still all completed on paper. The registered manager told us how they were keen to introduce the online system to ensure full oversight of all medicines.

During the inspection we found concerns relating to medicine management. This included concerns in relation to best practice guidance not being followed in some areas relating to dispensing, recording and guidance for medicines. Following the on-site visit the registered manager took immediate action to address the concerns, conducting an internal audit and seeking external pharmacy support. The registered manager provided further evidence to demonstrate the concerns had been addressed and actions were planned for continuous improvement in this area. We also received feedback from an independent pharmacist who had completed a follow up visit and commented on the vast improvement made. Staff used appropriate and safe storage and we saw staff administer medicine to people in a safe way. We saw evidence in all printed MAR charts of staff signatures and initials recorded. We also saw a returns book in place and signed by the pharmacy, this ensured all out of date or over-prescribed medicines were managed in a safe way. Regular staff training and competency checks were completed. However, previous concerns identified bought into question how effective these were.