Archived: Bethrey 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 service was not safe and remains rated as inadequate. We identified a continued breach of the legal regulations. People did not receive safe care as care plans were not reviewed or followed. Incidents continued to not be identified and actioned, which had resulted in harm for a person. Medicines were not managed in a safe way and people did not always receive these as prescribed or when needed. There remained no guidance in place for some people when they were prescribed ‘as required’ medicines.

This service scored 38 (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.

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

Staff and leaders continued to not always be aware of people’s risks and how to support people safely. For example, all staff we spoke with told us bedrails were used for a person who had been identified as being at risk from the use of bedrails. They were unable to provide an explanation for this. The provider was unable to assure us they were aware of incidents that had occurred in the home. When asked they did not offer us assurances they would take appropriate action to keep people safe. They failed to act when we raised concerns and told us, “It’s been noted”. They also confirmed the sensor mat we raised concerns about, “May still be broken.” The provider told us they were working through concerns we had previously identified and were making improvements.

The processes in place to manage risk continued to not be effective. For 1 person we saw 3 incident forms had been completed in September 2024 where they had ‘jumped/climbed’ over their bedrails and the sensor mat that was in place to alert staff they were mobilising had not worked. No action had been recorded or taken since these incidents had occurred. We reviewed the care plan, and it showed this person should not have bedrails due to the risks associated with their use. This placed this person at risk of harm. Another incident had occurred where a person had received an injury as they had removed the protective bumper from their bed. We reviewed the care plan, and it showed the removing of the bumper was a known risk to this person. However, no action had been taken following the incident to mitigate further risk, placing this person at risk of further harm.

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

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

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.

We asked the provider to show us records to confirm a staff member they had employed was trained and competent to administered medicines to people. Their response demonstrated they did not understand their responsibility to ensure medicines were safely administered. They told us that the member of staff had been appointed by their interim manager, so they had no knowledge of their skills, training or competence. Care staff we spoke with told us they were not currently administering medicines, they said they would raise any concerns with the seniors if needed.

When people were prescribed ‘as required medicines’ some people did not always have guidance in place to show staff when these should be administered. Other people had guidance in place for staff to follow. However, the guidance continued to lack sufficient detail to ensure people received as required medicines safely and consistently. When people had received these medicines, staff were not consistently recording why people had needed these. For example, we found instances where people had received medicines for agitation when there were no records to support they were agitated and other instances where it was documented they were agitated and they had not received these medicines. This placed people at risk of not receiving medicines how they were prescribed. We also found there were not always records to confirm a staff member who had administered medicines to people were competent or trained in relation to the administration of medicines.