Bede House

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

The provider did not always manage medicines appropriately or gather the required information when recruiting new staff. However, we did not find evidence this had directly impacted people's care. The provider had effective systems at Bede House for dealing with safeguarding matters. Staff completed safeguarding training. People confirmed they felt safe and could raise concerns. Risk assessments were completed where required. Staff supported people and relatives to make decisions about their care. Although people and staff gave mixed views about staffing levels, there were enough staff available to meet people’s needs. The home was clean and well-maintained.

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.

People and relatives gave positive feedback. A person told us, “I fell once in the home and the staff had to listen to my chest with the stethoscope. I was happy with how staff reacted.” A relative said their family member had been involved in incidents, which did not cause concern. They said, “The home took the appropriate steps, including raising a safeguarding and discussing with me in-depth.”

The registered manager gave examples of situations where people’s care had been reviewed following an incident and the lessons learnt to improve their outcomes. For example, seeking advice and guidance to support a person with communication difficulties. Lessons learnt were cascaded through staff meetings, supervisions and residents’ meetings where appropriate.

Individual incidents and accidents were investigated and action taken to reduce the likelihood of a repeat occurrence. The provider had systems to investigate and analyse incidents, accidents and complaints. An electronic tracking system had recently been developed and implemented at Bede House. This allowed the provider to more effectively identify and address themes and trends.

Most partners gave positive feedback about how well people transitioned into the home. They gave examples of how people had been settled in effectively. For example, through encouraging people to engage in activities and to socialise with others. They felt staff had taken time to get to know people well and encouraged them to bring personal belongings with them. Another health professional supported a person to transition from hospital to Bede House. They described how the service had made a 'real effort' to welcome the person, took time to get to know them, found out about personal preferences and encouraged them to bring in personal items to promote a homely environment.

Staff confirmed people's care needs were reviewed when they moved into Bede House. This included spending time with people and relatives to have conversations about their expectations and preferences.

Relatives gave positive feedback about their family member’s transition into the home. A relative said staff had been especially kind and helped their family member to settle in.

The provider completed a pre-admission assessment before a person moved to the home. This helped to develop care plans to help ensure they settled in quickly. This included gathering information from the person, their relatives and other agencies involved in their care. Specific documents, summarising people's care needs and preferences, were used to share information when people moved between services, such as hospitals.

People confirmed they felt safe living at Bede House. Relatives also agreed their family member was safe. A person said, “I feel safe living here, I don't feel like I have to lock my door.” A relative commented, “The family feels [family member] is safe. In the short period of time [family member] has been at the home, there has been more than enough staff on shift to meet [family member's] needs.”

Staff were careful when supporting people. They provided guidance and prompts for people, to help with providing safe care.

Where required, allegations of abuse had been referred to the local authority safeguarding team and investigated. Staff acted to address issues, such as re-educating staff and, in some cases, disciplinary action. Lessons learnt were also identified which included changes to moving and handling practice and other measures to help reduce potential risks to people’s safety. Staff completed safeguarding training, in order to develop their knowledge and understanding of how to keep people safe. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests (BI) and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider was meeting the requirements of the MCA. Where needed, authorisations for people being deprived of their liberty had been approved.

The registered manager demonstrated they had oversight of safeguarding issues within Bede House. Staff had a good understanding of safeguarding and were confident to raise concerns, when needed.

People and relatives gave positive feedback about the management of risk. A relative said, “[Family member’s] room has bed sensors, so they [staff] were aware as soon as [family member] got out of bed.”

Staff interacted positively when supporting people and provided person-centred care, choice and support.

Staff demonstrated they knew how to support people when they were distressed and how to respond to risk. Staff confirmed they had access to people’s care plans and risk assessments, which gave some guidance about the most appropriate action to take to help keep people safe. One staff member said, “If I see a change in a level of risk I would report to the nurse.”

Although staff showed they knew how to support people when they were distressed, care plans and risk assessments lacked information about the most effective strategies to use at these times. The provider was moving to an electronic care planning system and was reviewing care plans and risk assessments as part of this. Staff had access to information about people’s support needs in emergency situations. These were summarised into one place for ease, and included details of how many staff were required to support each person to leave the building safely and the equipment needed.

The building was purpose built as a care home and was well maintained.

The provider completed risk assessments and various health and safety checks to help maintain a safe environment. Where required, action plans were developed to deal with any issues identified.

Staff confirmed they had access to the equipment they needed to maintain a safe environment and had been trained to use it.

People and relatives gave positive feedback about the environment at Bede House. A relative said, “The home looks lovely, it is a lovely environment.”

There were sufficient staff on duty to meet people’s needs in a timely way.

Senior management told us they provided operational support with recruitment. The registered manager told us they were recruiting for bank staff to ensure consistency when staff were absent. They said new staff are allocated a mentor to provide additional support. Most staff felt staffing levels could be improved, although most felt they were not at an unsafe level.

People gave mixed views about staffing levels. A person told us, “I think there's just about the right number of staff to look after me.” Another person said, “We could do with a few more staff to help, as I don't think there is enough.” Relatives felt staffing levels were sufficient.

Recruitment records were not always in line with the provider’s recruitment policy. For example, information to make safe recruitment decisions was not always available, such as employment histories and references. However, staffing levels generally were appropriate to meet people's needs. The registered manager monitored the staffing levels to check they were at a suitable level to meet people’s needs. The provider used a dependency tool to help with this assessment.

The provider had effective IPC policies and procedures. Staff had completed training in how to promote good IPC.

Staff gave positive feedback about IPC practices in the home. One staff member said, “I think we're in a good place, we have got all the resources we need. We do a deep clean every day depending upon which room, 2 or 3 rooms are deep cleaned each day.”

People and relatives gave positive feedback about cleanliness in the home. A person said, “The home is spick and span clean, and staff wear aprons and gloves when they are helping the other patients.” A relative commented, “Domestic staff are around and the home is always clean and tidy.”

The home was clean and very well presented. Staff had the PPE they needed, which they used effectively.

People and relatives gave positive feedback about medicines. A person told us, “I do take medication and the staff give me this.” A relative said, “I have never been visiting when [family member] is administered medication. However, I spoke to the nurse to ask what they were having and the nurse explained everything to me in great detail.”

The provider did not always manage medicines safely. Records did not always accurately record stock levels and variable dose medicines. There also were gaps in medicines administration records. This meant it was difficult to ascertain whether these had been administered as prescribed. Guidance for when to administer ‘when required’ medicines was not always person-centred or detailed.

Staff told us the registered manager supported them with medicines. They had completed e-learning in various aspects of medicines management. The Home Manager had enrolled nursing staff on specific training in relation to promoting good skin care.