Beechcroft

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

We assessed 4 quality statements in the safe key question and found areas of good practice. The scores for these areas have been combined with scores based on the last rating which was requires improvement. The assessment of these areas indicated areas of good practice since the last inspection, our rating for the key question has improved to good. There was a culture of safety and learning. Risks were not overlooked or ignored and were treated as an opportunity to put things right, learn and improve. People and staff were supported to raise concerns. Incidents and complaints were appropriately investigated and reported. Risks were assessed, and people and staff understood them. Recruitment practices were safe to ensure staff were competent to carry out their role. There were appropriate staffing levels and skill mix to make sure people received safe, good quality care that met their needs. People’s medicines were appropriately administered. There were appropriate arrangements for the safe management, use and oversight of controlled drugs.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People's feedback confirmed there was a culture of safety and learning and that risks to people were managed and not overlooked. One person told us, "Yes I feel my risks are managed."

Feedback from staff and leaders confirmed safety was a top priority for everyone. Staff demonstrated they understood their responsibilities to raise any concerns. Lessons were learnt with opportunities to learn from safety events being communicated to help support improvement. The provider confirmed, “We learn as we are open, we have flash meetings daily. Here we talk about updates, changes and any incidents are discussed, we will remind staff about training and policies relevant to incidents.” A staff member added, “We do definitely learn from incidents, and we have meetings which are useful.”

Processes helped enable opportunities to learn from any safety incidents and near misses. For example, relevant policies such as the falls policy and safeguarding policy, provided guidance for staff and there was evidence of lessons learnt from minutes of staff meetings. Transparency about safety was encouraged and used to help drive up improvements.

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.

People's feedback confirmed people were informed about risks and how to keep themselves safe. Comments from people included, “A risk to me is medicines, and this helps me with risks as I would get muddled up” and “I feel safe living here.” However, although people’s care records showed there was a balanced and proportionate approach to risk, we couldn’t always be assured from records that people had been involved in their review.

Feedback from staff and leaders confirmed risk assessments were person-centred, proportionate and understood by staff. A member of staff told us, “Risk assessments are person centred and not overly restrictive.” Managers told us how people’s risk assessments were reviewed as a minimum monthly, and again, after any significant changes, for example, following an admission to hospital. The area manager told us, “If a person is admitted to hospital, the care plan freezes until they are discharged, prompting us to review risk to that person on their return.”

We observed people's care needs being met in a safe and dignified way. Where people required assistance with mobilisation, staff provided this by using appropriate mobility aids. We observed people in the dining room, where people required assistance with their dietary requirements, this was offered in a considered way, which respected people's independence.

Established processes helped ensure the provider embedded a proactive approach to anticipating and managing risks, with the least restrictive option being considered. People’s risk assessments were person-centred and proportionate; however, they did not always evidence they had been reviewed with the person. Processes were also in place to help identify any themes and trends that may arise from risk processes and incidents, to help ensure the provider had an accurate and up-to-date picture of risk. Although we were assured staff had a good understanding of risks to people, daily care records did not always evidence that care had been delivered as prescribed. For example, for people at risk from skin integrity and who were on regular changes of position, records did not always evidence this had been carried out as often as it should.

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

People’s feedback confirmed they felt safe when staff were providing care and support and their care was delivered by staff who were trained and competent. People told us they thought there were enough staff and their needs were met in a timely manner. Comments from people included, “I would talk to staff if I had any issues at all, staff are trained and know what to do. I feel safe. Staff help me and wash and dress and I have choices in the time I get up and go to bed” and “Although I am able to do a lot for myself, I think there are enough staff, and they are trained.”

Feedback from leaders confirmed processes and practices were in place to help ensure there were enough suitably trained staff to meet people’s needs. The registered manager told us, “New staff are linked up with a buddy for several months to help support them in their role.” Staff told us, “We have a mixture of face to face and online training, and it’s refreshed” and “The managers sometimes put a file together with policies they want us to revisit, this is helpful.”

We observed enough staff on duty, including nursing staff. People’s needs were met in a timely way. The environment was calm and relaxed. There were positive interactions between people and staff, who were familiar with the needs and preferences of the people they were caring for.

Processes were in place to help ensure staff were recruited safely. New staff were supported by an induction programme and support for staff continued in the form of training, supervision and appraisal. For any staff who belonged to an external regulating body, such as nursing staff, checks were place to ensure their registration and conditions of practice were up to date.

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.

People’s feedback confirmed they felt staff assisted them with their medicines in a safe way. For people who were prescribed painkillers, they told us they received these medicines on time and when they needed them. Comments from people included, “Staff help me with my medicines every morning, I get them at the same time” and “I am on painkillers, and I get them when I need them.”

Feedback from managers confirmed medicines were administered by suitably qualified staff and staff who had undergone competency checks. One member of staff told us, “I am well supported, I give out medicines.”

Processes were in place to help ensure people were involved about the level of support they need to manage their medicines safely and to make sure their preferences were included, which was recorded in their care plan. People’s medicines were administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. There were appropriate arrangements for the safe management, use and oversight of controlled drugs. Daily stock balance checks were carried out daily to help reduce the risk of errors. We did observe some areas which required improvement, for people who were prescribed dermal pain relief patches, rotation charts had not always been completed accurately. This is important for ensuring staff were not using the same skin site at each application. For people who were prescribed PRN (as required) medicines, protocols were not always in place. This is important, as protocols provide staff with guidance for when these medicines should be given. Medicines kept in the fridge did not always record the date of opening. However, the provider’s own audits had already highlighted these shortfalls and actions were in progress to make the necessary improvements.