Beaconville Nursing 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

Some aspects of the running of the service were not always safe. There were sufficient staff to meet people's needs. However, staff were not being provided with regular supervision, appraisal or training updates. People told us they were happy living at the service. However, we found the environment required some improvement. There was a service improvement plan in place. However, the plan had not identified the concerns found at this assessment. Care plans were in place detailing people's needs and risks. However, we found risk assessments were not always accurate or up to date, did not provide staff with sufficient guidance and direction and placed people at potential risk. Medicines were not always well managed. This led to a breach of Regulation 12, Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) 2014.

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.

Staff told us they were happy to speak up and report issues. Staff said they were supported by the nurses and managers and things were discussed in handover when necessary.

The service did have a service improvement plan in place to support continuous improvement. However, governance and performance monitoring processes were not always reliable and effective. The plan did not identify the concerns found at this assessment.

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.

People, who were able, told us they felt safe. One person said, “I don’t feel unsafe at all.” Another person nodded when they were asked if they felt safe and said they were “ok.” People’s relatives also expressed how happy they were with the service people received and that people were, indeed, safe. One said, “Yes, he seems to be happy and safe yes - very much so. No concerns and if anything happens they ring and they tell me all about it.”

Staff were aware of how to report any safeguarding concerns and were knowledgeable about the types of abuse and the need for it to be reported.

Where people had restrictions in place to keep them safe, authorisations had been applied for. However, records we saw did not make it clear who had authorisations in place and when these needed to be reviewed. We recommend the provider seeks advice from a reputable source regarding how to keep records clear and regularly updated. The service had systems and processes in place to prevent abuse for the people using the service. The service had taken appropriate action, where any form of abuse was suspected, and had reported this to the appropriate agencies.

People, wherever possible, and their relatives were involved in their care planning and managing risks associated with their care needs. One person told us their care was discussed with them, they said, “At the beginning yes, and any changes along the way are discussed with me.”

Staff were attentive to people’s needs and knew how to support them safely. Equipment was in place to support safe handling and to protect people from the risk of skin damage. We observed staff using equipment safely during the visit. We observed staff provide choice and independence to the people who were using the service while supporting them with nutrition and hydration needs.

Care plans and risk assessments were not always accurate and up to date and some lacked sufficient guidance about how to manage or mitigate risk. This placed people at potential risk of harm. Care plans did not always give sufficient detail about how staff should support people who displayed behaviours that may pose a risk to themselves or others, including what triggered their behaviour and techniques to help de-escalate behaviours. Risks associated with people’s skin were not always being fully mitigated. Records did not always demonstrate that people were being repositioned according to their assessed need. Care plans and risk assessments in relation to people’s falls risk were not always accurate and consistent. This meant people may be at risk of falling as staff did not always have access to accurate information. Care plans and risk assessments did not always contain sufficient detail in relation to supporting people to eat and drink safely. People who were at risk from losing weight were being monitored and weighed regularly and advice had been sought from people’s GP and dietitian about how to help the person gain or maintain their weight. People were receiving nutritional supplements and fortified diets. People at risk from choking were being managed well. People had been assessed by the SALT team when needed and were receiving appropriate modified diets. We observed people being supported to eat their meals safely and in line with their assessed needs.

People did not always live in a safe or pleasant environment. The service was generally run down and had heavily stained, worn and ruckled up carpets in communal corridors which posed a trip hazard to people living at the service. We discussed this with the registered manager on the first day of the site visit. On the second day the registered manager told us as a result of our observations the provider was going to replace the carpets in all communal corridors of the service.

Staff told us they worked as part of a good team. Staff said they were well supported by management and received a good level of training and induction

We observed there were sufficient numbers of staff who were quick to recognise people's immediate needs and respond appropriately. Where people required one to one support to keep them and others safe, we saw this was happening.

Supervisions of staff were not always taking place regularly. Appraisals had not always taken place annually. Staff meetings were not held regularly. Staff training was not always updated when required. However, this had been identified by the provider and plans were in place to address these issues.

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

Medicines were not always managed appropriately. Medicines management was being carried out by the registered nurses and head of care. The head of care and clinical lead were open and honest about the challenges they had encountered recently. These included taking steps to ensure there was a robust stock check process in place, inappropriate blanket covert medicines policy in place for everyone and a lack of PRN (as and when medicines) protocols.

Where people were prescribed medicines to be administered as and when required (PRN), guidance was not in place to inform staff when the medicine would be appropriate to be administered to people. Medicines and liquids were not always dated when they were first opened. This meant staff could not tell how long the medicines had been in use and when it would be out of date. Staff told us despite some people being able to consent to receiving their medicines there was a blanket covert ‘policy/practice or understanding’ in place not based on assessment of need, rather as a ‘just in case’ assumption. The registered manager confirmed that all people had covert instructions in place. Staff recorded when people’s medicines were administered. These records showed people received their medicines in the way prescribed for them. This included systems in place to record when creams or other external products were applied. Medicines were being stored appropriately. This included those needing cold storage and those needing extra security. Room and fridge temperatures were being checked daily.