Beech Hill Grange

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

Systems to ensure people were safe from possible hazards in the home were not always effective. Some staff were using unsafe manual handling techniques to support people. Not all staff had completed fire safety training. There had been no provision within the night care team to ensure those expected to lead in the event of a fire emergency could do so effectively. This was a breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. Accidents and incidents were not always recorded in line with the provider’s policy and procedure. Safeguarding concerns were not always identified, investigated or shared, when appropriate, with the local authority safeguarding team to explore any risks of neglect or abuse. Lessons were not learned consistently to mitigate risks and protect people from avoidable harm. This was a breach of regulation 13 (Safeguarding service) of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. We identified some concerns in the recording and management of medicines. Staff did not always have the training and support needed to ensure consistent high-quality care. The home was clean and well maintained. Infection prevention systems were effective.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed reviews from people living at the home and their relatives about the learning culture of the staff team. Two relatives told us they had recently raised concerns about their loved ones and felt satisfied with how these had been dealt with. One relative told us, “They [staff] followed it all through to the end. They communicated well throughout.” However another told us they had repeatedly raised concerns about their loved one and had not felt listened to.

Care staff routinely photographed and recorded unexplained injuries. They told us they then informed the nurse on duty of the injury. Although staff we spoke with told us they would record all incidents and accidents according to the policy and procedures of the home, we did not always find this in practice. One staff member told us when they had enquired about what steps would be taken to look into the injury someone had sustained, they were told it was ‘not for them to know’. We identified a broader theme of care staff not being included in key processes to inform the quality of care. These included handover meetings, care plan reviews and lessons learned processes. We spoke with the interim manager about how they were managing complaints and concerns. They told us they had no access to any system which might have been in place under the previous manager to record complaints and actions taken to respond to them. They shared emails evidencing some aspects of complaints had been considered, but there was no complaints log in place to show what concerns people had raised, what action had been taken and what lessons could be learned for future practice. A complaints log was created for this purpose during our assessment.

Systems to ensure risks were identified, mitigated and lessons learned from them were not robust. None of the staff we spoke with were able to recall examples of lessons learned when things had gone wrong. Staff were not taking part in regular meetings to share information about lessons learned or good practice examples. Staff were not always identifying and reporting accidents and incidents in line with the provider’s policy and procedures. When accidents and incidents were identified they were not always investigated to identify a root cause and prevent future risk. For example, there was no falls analysis being conducted by management. The management team were unable to provide evidence of ways in which information about falls was being used to reduce future risks. When incidents were recorded, lessons were not always learned from them. For example, a person had tripped over a hoist and sustained serious injuries, but this had not resulted in a review of the storage of hoists in the home. During our assessment there was no evidence of a complaints log being used. A complaints log was later located by the new home manager. The log did not however demonstrate how lessons would be learned, or how the management team would ensure suggested changes were effective. Concerns were not always raised with external agencies when appropriate; this led to a closed culture in which concerns were not identified and investigated thoroughly. Opportunities to reduce risk and harm to people were missed. We shared these concerns with the provider, who told us they were making changes to improve the learning culture of the service.

We received mixed views from people and relatives about their involvement in care planning. One relative told us they were happy with their involvement in the planning of their loved one’s care. They said, “They [staff] involve us in all parts of [the person’s] care. I am happy with it.” However, most people and relatives we spoke with said they had not seen their care plans and had not been involved in reviews of their care. One relative told us about their loved one being transferred from hospital to Beech Hill Grange. They said, “[The staff] mapped all [my loved one’s] body following a hospital stay…. They looked after [them] well.”

Nursing staff told us they called people’s relatives to update them when reviewing care plans, but 1 nurse we spoke with told us care plans were not updated as regularly as they needed to be because the team were busy and reviews fell behind schedule. The interim manager told us much of the pre-assessment process and initial care planning fell to the clinical lead, but this was too much for 1 person to manage and they intended to share this task amongst the wider nursing and care staff teams. Nursing staff were able to tell us about the steps taken when people were being transferred in and out of hospital to keep them safe and ensure effective communication.

There was sometimes little evidence in people’s care plans of how they had contributed to their development. Some care plans were not updated regularly and contained out of date information. For example, an incident report showed a person had been found to have an unconsumable item in their mouth which posed a risk of choking. The action plan suggested the person be prevented from accessing this item to mitigate the risk. However, this information was not in the person’s care records to ensure staff caring for them were aware of the risk. There was no evidence people had come to harm as a result of key information not being shared with care staff or other medical professionals, but the risk of sharing information which was not up to date was not mitigated. The interim manager told us they had plans to involve people more in the development of their care plans and would be taking part in a review of all care plans to make sure they were up to date and accurate.

Most people and relatives we spoke with told us they felt safe living at Beech Hill Grange. Some people described how staff supported them to move safely with the assistance of a hoist, which reduced their anxiety about using this equipment. A relative told us, “I am 100% confident [my loved one] is safe here.” One relative we spoke with told us they had felt, at times, their relative was not safe. They told us their relative had developed health conditions which the staff team were slow to respond to. They told us, as a result of this delay, their loved one had experienced unnecessary deterioration. Two relatives told us they had noticed their loved ones had experienced unexplained injuries. In both cases they said when they raised a concern about these they were happy with the response and reassurance they received. However, in both cases, they noted the injuries and asked about them and were not advised of the injuries first by staff.

Discussions with staff and leaders indicated they were not always following the provider’s policies and procedures to ensure people’s safety. The interim manager explained there was no safeguarding log in place to monitor concerns, record investigations and outcomes and recommend changes to prevent future risk. A basic log was created during our assessment. A historic safeguarding log which had been used by the previous registered manager was later found, but this had not been kept up to date. Staff were able to tell us, in principle, what action to take in the event of a safeguarding concern, but in practice we found procedure was not always followed. Most staff did not express concerns about the way injuries were recorded and investigated. However one staff member told us they were concerned about the amount of unexplained injuries people were sustaining and felt they were not always being investigated properly. Some staff were not clear about who would lead in the event of a fire emergency. Some staff also told us they had not completed fire safety training or participated in fire drills. The interim manager told us they had introduced new daily checks on the safety of the home’s environment, which included health and safety checks. However, these had not enabled the management team to identify some of the concerns we found during our assessment.

We saw evidence of poor oversight of health and safety in the home. During visits we saw some examples of poor manual handling practice. We saw staff attempting to help seated people to stand by lifting them by their hands. We also saw 3 staff carrying a person in an adapted chair through an external doorway, because none of the staff knew where the ramp for the doorway was.

The provider’s health and safety systems had not enabled them to ensure people were always protected from avoidable risks in the environment and from the risk of unsafe or inappropriate care. A review of incident and accident records showed there was no clear system to ensure proper oversight of what staff were recording, or to ensure incidents and accidents were being reported appropriately. For example, records showed 1 person had sustained an unexplained skin tear, but this had not been recorded as incident or accident in line with the provider’s policy and procedures. Another incident report showed a person had sustained an unwitnessed head injury, but records could not confirm they had received the appropriate medical care. We saw some incidents and accidents had not been shared with the local authority safeguarding team in line with the provider’s policy and procedure; this included a person who had sustained a number of unexplained bruises and a skin tear over the previous 2 months. The provider’s incident and accident forms did not include a prompt to consider sharing concerns with the safeguarding team. Incidents and accidents were not assigned to a specific manager to review and were not signed off as complete. We raised these concerns with the interim manager and shared our concerns with the local authority safeguarding team. The provider told us about changes they had introduced to improve monitoring of injuries to people.

Most people and relatives told us they felt supported to manage risks well. One relative told us they saw staff were always on hand to support their loved one if they wanted to walk because they could be unsteady. Another told us their loved one was always supported to use their mobility aid for stability. Relatives also told us staff were able to communicate with their loved ones well.

Staff told us they mainly supported the same group of people and got to know their care needs well. However, management of risks for some people was not effective. Staff told us about ways in which they supported and communicated with people who could become very distressed. However, we found the guidance staff had received on supporting people when distressed was limited. Some had learned about triggers for people and what could be effective to help calm them, but this learning had not always been included in the care plans to share good practice with other staff. Staff told us they often had to work with agency staff who may not know about people’s risks. Two staff told us agency carers did not always know how to access care plans electronically. An agency staff member also told us they could not access care plans; this left people at risk of not receiving safe and effective care. This risk was partially mitigated by deploying agency staff alongside regular staff and trying to use the same agency staff members. People were offered alcohol both at 11am (sherry) and at lunch time (wine). Staff told us anyone who wanted alcohol could have some, it was their choice. However, some people had health conditions and medications which would make alcohol use dangerous for them. This risk had not been assessed. In addition, not everyone was able to make an informed decision about whether alcohol was safe for them. We raised this concern with the new home manager and provider who told us they would risk assess alcohol use for people on an individual basis.

We saw some people being supported well to manage their risks, but overall risk management for people required improvement. We saw examples of changes made to people’s care to help support them with risks to their wellbeing. We also saw examples of risks for people not being managed well. For example, many people were cared for mainly or exclusively in bed. These people were isolated in their rooms for long periods of time without company or stimulation. We viewed care plans and saw risk assessments had not been completed to consider the risk to people’s mental health from the possible isolation of being cared for in their rooms. The rationale for why people were being cared for in bed was also not always clear. We saw on 2 occasions people were left unsupervised in the piano lounge area. On 1 of these occasions a person whose care needs were under review following a period of ill health and hospitalisation, tried to walk unaided. Staff had to be called to the area quickly to provide support. We spoke to the interim manager about this. They told us the piano lounge was, historically, more for people who could be left unattended for periods of time. They confirmed there was no policy or procedure in place regarding the use of this part of the home and no guidance about whether the area should be staffed when it was in use. They advised that a policy and procedure would be written and put in place to address this risk. We saw 1 person who had been living at the home for 2 months had no care plan or risk assessments in place. They had needs associated with their mobility and had sustained an unexplained skin tear. It was not clear whether this skin tear was a result of risks linked to mobility, but staff had had no clear guidance about the person’s needs or risks to demonstrate they had been reviewed and mitigated. We saw risk assessments for people taking strong sedative medication did not include guidance on whether it was safe for them to consume alcohol.

Systems to audit and ensure care plans and risk assessments were up to date and contained sufficient guidance for staff to support people with their risks effectively were not robust. The knowledge staff had gained from caring for people over extended periods had not been incorporated in some cases. Guidance for staff to support people who could become distressed during care was not always detailed or sufficient. This left people at risk of unsafe and inappropriate care. One incident report recorded that a person had been shouted at by a member of staff. There was no evidence of an investigation to consider what had led to this happening and what support both the person and the staff member needed to cope in challenging situations. We reviewed the use of medication for someone who could become distressed whilst receiving support with their personal care. The PRN (as needed medicines) guidance suggested they should be given the medicine before being offered care. There was little guidance for staff about other measures they could take to help calm the person before and during personal care. There was little evidence the medication was being used as the least restrictive option. In many cases, care notes indicated the person had been woken to administer the medication, therefore, not being afforded any opportunity to express whether the medication was needed or not. This was evidence of chemical restraint. We shared this concern with the provider and new home manager as well as the local authority safeguarding team.

People and relatives told us they were happy with how the facilities in the home were maintained. They told us they felt the home was maintained to a good standard and supported people to live there safely.

Although staff were able to tell us about many ways in which the safety of the home was maintained, we identified some key areas of concern. Staff told us they were storing hoists in the corridors. The interim manager confirmed the hoists did not have designated safe storage areas. The interim manager told us they had introduced daily walk around checks of the environment. They told us they had discussed longer term plans to store the hoists safely, but the risks of causing a trip hazard in the interim had not been assessed or mitigated. We spoke with the maintenance operatives who told us about the many checks they did to maintain the safety of the environment, including the décor of the home and garden maintenance.

We saw hoists were left out in corridors throughout the home, as there was no designated area for them to be stored, posing a trip hazard to both people and staff. We saw a hot water dispenser in the bar area of the dining room was accessible to anyone who could walk independently, even though some of those who could walk independently may not be safe to use a hot water dispenser without risk of scalding. We saw an area beneath a fire escape route was being used for storing combustible items, posing a risk to compromising the escape route in the event of a fire. We raised all of these concerns with the interim manager and the provider and steps were taken to address them in a timely manner. We saw the home was tidy and free from clutter and décor was generally well maintained.

The provider’s systems in place to ensure the home was maintained to a good and safe standard had failed in some areas. Systems to identify hazards in the home had failed to identify the risks posed by the lack of hoist storage, unrestricted access to the hot water dispenser to people who could walk unaided and the risk of compromising a fire escape route by storing combustibles beneath it. Combined failings to ensure all staff had fire safety training, participated in regular fire emergency drills and understood the procedure to follow in the event of a fire placed people at increased risk of harm in the event of a fire emergency. After we made them aware of these concerns, the interim manager reviewed staff training records and put a plan in place to ensure all staff had fire safety training and there would be sufficient staff trained to lead in the event of a fire emergency.

We received mixed views from people and relatives about staffing numbers. Some people told us they thought the home was sufficiently staffed. One person told us the service was sometimes short-staffed and on those occasions it could take a while for them to answer the call bell, but usually staff came quickly. Two relatives told us they felt staffing was an issue at particular times. One told us they did not think there were enough staff to support mealtimes and, as a result, sometimes people’s meals were going cold. Another relative told us they had raised a complaint because their loved one had been put to bed during a weekend because there were not enough staff on duty. Most people spoke positively about the care team’s skills to provide good care. One relative told us they felt some staff could benefit from better training to understand dementia, because they had heard them speaking to people living with dementia in a way which suggested a lack of understanding of their condition. People and relatives agreed they were generally supported by the same staff team which they felt was beneficial, enabling staff and people to get to know each other.

Staff spoke positively about their induction when joining the service. They told us they had not experienced the service being short-staffed and agency staff were utilised whenever possible to cover absences. Staff expressed mixed views on the training they received to fulfil their duties. Some staff told us they had not had training in key areas, such as fire safety and dementia. Staff told us they mainly did e-learning each year and only had face-to-face training for manual handling. Some staff told us they thought the quality of the training was good, whilst others felt it could be improved. Not all staff had received supervision in line with the provider’s policy and procedures. One staff member said they had never had supervision, one staff member said they could not recall the last time they had supervision and most told us they had never had an appraisal. However, all staff said they felt supported and told us they could share any concerns with the management team. One staff member told us there was no rota for staff taking breaks and they saw some staff regularly tended to take their breaks all at the same time. This left people at risk of being left unsupervised and unable to receive help quickly if they needed it. We told the new manager about this and they gave assurance that a rota would be put in place to make sure staff staggered break times. Some staff told us they felt learning opportunities were limited. One staff member told us they were denied the opportunity to gain extra qualifications because they would ‘move on.’ Another told us they felt stuck in their role with no opportunity for career progression. The provider told us they had plans to create roles which would give carers more opportunity to develop further skills and expertise

We saw some staff were using unsafe moving and handling techniques. We shared this with the interim manager who made sure staff received refresher training in moving and handling during our assessment. We saw adequate levels of staff during our visits. Staff appeared unhurried and we saw some positive and meaningful interactions between staff and people. However, we saw some people had extended periods of time without stimulation, especially people being cared for in their rooms. The interim manager explained they were currently recruiting to increase the size of the activities team to address this issue.

Processes to record and monitor recruitment, training and supervision activities were not effective. The management team did not maintain consistent and accessible records to demonstrate staff had had Disclosure and Barring Service (DBS) checks as part of safe recruitment practices.. Some staff who had disclosures about historical offences and concerns the DBS deemed relevant to record, had not had a risk assessment completed to show how the possible risks were being monitored. We raised this concern with the Interim manager who then completed these risk assessments as needed. Training records had not been kept updated and did not allow easy oversight of staff compliance with training. For example, records showed many staff had not completed fire safety training. Some of the staff listed on these training records no longer worked for the provider. The management team were unable to show staff compliance with the provider’s key training requirements and could only view 1 staff member’s training record at a time. The provider later informed us more staff had completed training than the records suggested, as the records had also not been updated when new training had been completed. There was no staff supervision matrix in place to monitor when staff had last had supervision. The provider’s systems did not demonstrate that training had been effective to improve the quality of care provided.

People told us they were happy with the cleanliness of their home. Relatives agreed the home was maintained in a clean and tidy way. They also told us their loved ones were supported to maintain good levels of personal hygiene.

Staff spoke highly of the team who cleaned the home. They told us they worked in a clean and hygienic environment. Staff told us they were always supplied with plenty of PPE (personal protective equipment) and hand sanitizer. They told us about the circumstances in which they would use the various types of PPE available. The management team told us about steps they took to limit the transmission of infections within the home. During our visits, 2 people who had developed coughs and symptoms of a possible cold or flu were being cared for in bed to limit the risk of spreading infection.

We saw the home was clean, tidy and uncluttered. The décor was generally well maintained as were the gardens. People looked clean and well presented.

Systems to ensure the home was kept clean and hygienic were effective. People were protected as much as possible from the risk of infection because of the effective systems in place.

People told us they were happy with the support they received to take their medicines safely. One person said, “They [staff] bring me my medicines every day; they’ve never forgotten.’ Relatives told us their loved ones received good support to take the medications they needed.

People’s medicines were administered by the nursing team, of which there were at least 4 on duty throughout each day and 1 each night. They were supervised and supported by a clinical lead. In discussion, the nursing team described good medicines practices and administration. However, we found concerns about the use of PRN (‘as needed’) medication and inaccuracies in the electronic medication records (EMAR). A nurse told us they had to complete yearly refresher training. They also advised the clinical lead observed their practice and audited the electronic medication records (EMAR) to make sure they were accurate.

We reviewed the use of sedative medication for 1 person, which was prescribed on a PRN (‘as needed’) basis. There was disparity between the number of days the person had received this medication in their EMAR in comparison to the daily care notes. The EMAR suggested there were 4 days in a 42 day period where the person had not received the sedative medication. However, the daily care records indicated they had received the sedative on 3 of those 4 days. This discrepancy had not been identified by checks of the records or the stock levels. Although recorded in the daily notes, the doses of the medication administered was not clear from the EMAR as the sedative was being signed for without clear indication of what dose was being given. There was no record of the reasons why the sedative was being given on each occasion, or the possible impact of the use of the sedative. Records, therefore, could not demonstrate staff were monitoring the effectiveness of the medication. According to their EMAR, 1 person had gone without a medication they were prescribed twice per day, for 8 days in a 10-day period. Records showed staff could not locate the medication, or that there was none in stock. There was no evidence to show replacement medication stock was sought in a timely way to ensure the person received it as needed. There was no record of consideration of the possible impact on this person from not receiving their medication during this period, which could have been potentially serious. We brought these matters to the attention of the provider and new home manager and shared our concerns with the local authority safeguarding team. The provider told us these concerns would be looked into. We observed good practice when people were receiving their medicines. People were receiving support to have prescribed creams administered in line with prescriber’s instructions.