Bethany Lodge

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 were in place to manage incidents and accidents. Action was taken to reduce the risk of incidents re-occurring. When things went wrong learning was shared with staff. Safeguarding’s were reported and appropriate action taken. Medicines were administered as prescribed. Medicines were stored and managed safely. Staff had the skills and knowledge they needed to provide people with safe care. Staff were supported in their role and were supervised appropriately. There were spot checks on staff performance and staff competency was assessed. There were enough staff to keep people safe. Although staff, the manager and people agreed there could be more staff to support people to engage in more meaningful activities. Care plans and risk assessments provided staff with the guidance they needed to support people to remain safe. Although there were some areas where some further work was needed in areas such as oral care. However, staff knew how to support people.

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 told us they were happy with the service and were kept informed about events that occurred as appropriate. One person said, “Yes, I feel very safe and happy here. Staff are amazing and tell me everything.” We saw from incident records that relatives were informed of incidents involving their loved ones.

Staff knew how to report incidents and were encouraged to do so by the registered manager. Staff told us, “Preventing harm is the priority. I have no problems talking to anyone here. The management and nursing team here are open and encourage reporting of any concerns you may have. It’s a positive and open culture here.” There were daily meetings for staff during which recent incidents and accidents were discussed and lessons learnt were shared. Where appropriate, de-briefs were undertaken with the staff involved, to review incidents and reflect on if things could have been done differently.

There were systems and processes in place to report and record incidents. When incidents happened, staff informed the nurse and team leader and updated the electronic system. This information was then reviewed by the registered manager or deputy and automatically uploaded to the providers system for trend analysis. Action was taken in response to incidents to reduce the risk of re-occurrence. A bulletin of lessons learnt and actions taken was produced for staff to keep staff informed. Some incidents were progressed to a ‘rapid incident review’ to ensure the right actions had been taken and the information had been shared appropriately in a timely manner, and to act if this had not occurred, to ensure actions were not delayed.

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 and their relatives told us they were safe at the service. One relative said, “I can say that because they found a bruise on [my relatives] shoulder, and they went through all the procedures. I was informed immediately, and it was looked into. It was from a [item of equipment used to support the person]”.

Staff we spoke with confirmed they had received training on safeguarding. Staff knew how to identify safeguarding concerns and what actions to take. Staff trusted the management to take action to protect people. Staff told us, “I’m very confident about raising a concern. They definitely listen to you here. I wouldn’t have any problems taking things further if I needed to.” Another staff said, “I am very confident to raise any issues and concerns; I am confident because I know what I am doing, and that by reporting, I am doing the best I can for that person.” Staff knew how to whistleblow if they needed to do so, one staff said, “If needed, I know to escalate higher and contact the local authority and CQC.”

Staff were present to provide support to people as needed. There was also equipment in place to support people such as pressure reliving mattresses, sensor mats, moulded wheelchairs, hoists, and slings all of which appeared clean, well maintained and in good working order. The service smelt clean and the temperature throughout the building was pleasant and warm with natural light. Corridors were uncluttered so people could move around without risk of harm from trip hazards. People were relaxed in the company of staff and the atmosphere was pleasant and friendly.

Staff had completed safeguarding training. This was both online and face to face training with staff working toward level 3 safeguarding training. Safeguarding concerns had been reported to the local authority and CQC as required. When safeguarding incidents had occurred action was taken to reduce risks and lessons were learnt to reduce the risk of similar events occurring. Concerns were shared quickly, safeguarding processes followed, and referrals made appropriately. The service worked with people, staff, and relatives to understand what being safe meant to them, and there was a focus on improving people’s lives while protecting people’s right to live safely, free from avoidable harm and neglect. 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. People can only be deprived of their liberty when this is in their best interests 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). There were systems in place to ensure authorisation had been sought where people were deprived of their liberty and that this was done legally and for the right reasons.

People were supported with their health needs to ensure they were safe. One relative said, “[My relative] was coughing and coughing, and they were there within minutes.” They told us they felt their loved one was well supported with their health needs. Staff had regular contact with peoples loved one to discuss changes in their care, mood and any risks where this was appropriate. Some people found the introduction of new staff to be stressful. However, the registered manager was aware of this and was taking people’s feelings and worries into account introducing new faces at a slower pace to support the person to build new relationships.

Staff knew how to support people with risks to their health. For example, staff knew what to do if someone had a seizure or how to identify if a diabetic person was unwell. Staff spoke with confidence when we spoke with them about people’s care. The registered manager had started in post in the autumn of 2023 and had made some changes to the service which staff were positive about. Staff told us, “There have been a few changes in the last 4-5 months and on balance it’s been positive and for the benefit of everyone, for example, getting rid of mobile phones on shift as this helps staff concentrate and, from my perspective, is spot on.”

People were supported to be safe at the service. We saw staff supporting one person to sit upright before eating. They explained to the person that it helped reduce the risk of them choking whilst eating. For another person who could become unwell in the hot weather, staff ensured they had a cooling fan on close to them to keep them feeling cooler. Staff frequently checked with the person and asked them how they were feeling, and asked if they needed the fan adjusted.

Care plans and risk assessments provided staff with the information they needed to support people. The registered manager had been focusing on supporting staff to improve care plans and guidance on people’s risk assessments. This was reflected in the plans in place where for the most part there was a good level of information about people’s needs. For example, there was clear information about one-person seizures including how to support the person if they wanted to have a bath. However, there were some areas where work was needed, such as oral care plans needed to be improved, although people were receiving dental care. The registered manager was aware of this and was addressing concerns. This was an area for improvement.

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 told us there was enough staff to support them to be safe. People told us staff responded quickly to their requests. One person used nonverbal communication to tell us staff came quickly when they requested assistance. One relative said, “Staff are always around and [my relative] has a buzzer by the bed”. However, people also told us they wanted to go out more and have more support to undertake activities. One person said they wanted to go on holiday. The registered manager agreed there would be a benefit to people if there were more staff. They said, “With a greater staffing level we’d have more meaningful engagement and improve greater levels of independence for the residents.” They told us they were seeking to review people’s support with commissioners to this end so this improvement could be made.

Staff told us, “We’d like to have more staff to be able to go out with the residents more. There are days when someone calls in sick. We have enough, we are not short staffed, we just know that more staff would give us more time to give people more social time.” Another staff member said, “Staffing is efficient, we are not overstaffed or understaffed. In my experience, the staffing number has always been safe.” Staff were positive about the training they were undertaking as the registered manager had been prioritising updating staff training. One staff said, “We are swimming in training. I feel there is enough and it’s of good quality.” Staff also felt well supported in their role. One staff said, “[The seniors] are so supportive – they really go out of their way, go above and beyond. For example, if I need help, they will take time out and show me, nothing is too much.”

The atmosphere was generally calm and there were some people and staff engaged in board games/activities. Staff were listening and respecting people’s personal choices and were at eye level and speaking quietly, kindly, and respectfully with people. Staff appeared to be aware of people’s needs and preferences. Where people had chosen to remain in their room staff were observed saying hello and checking people were safe and not in need of support. These residents were listening to their own music or watching film, or TV programme/s. If people called for help the call bell was responded to quickly.

There was enough staff to ensure people were cared for safely. Staff had the skills and knowledge they needed to provide people with effective support. Staff training was a mixture of online and face to face training. Staff were updating some non-annual training where they had not undertaken a course for some time. For example, staff were undertaking updated training on supporting people with modified diets. Staff received effective support, supervision, and development. Staff competency was checked where appropriate, for example to ensure staff knew how to support people with their medicines safely. Appropriate checks were undertaken to ensure staff were recruited safety. For example, Disclosure and Barring service (DBS) checks were undertaken. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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 were positive about the support they received with their medicines. We asked people if staff supported them to take their medicines on time, one person said, “Yes, they always do, I believe they do, they have to”. Another person uses nonverbal communication to indicate yes. Staff spoke to people about their medicines before they provided support. One person said, “They ask consent and explain what’s happening”.

People’s medicine was administered by registered nurses. Staff knew not to interrupt the nurse when they were administering people’s medicines to enable them to concentrate and reduce medicine errors. If there were errors staff knew how to identify and report these.

People’s medicines were managed safely. Medicine administration records (MARs) were completed clearly and accurately. MARs included the information staff needed to support people safely with their medicines. Where people were prescribed as and when medicines there was appropriate guidance in place for staff to ensure staff knew when and how to administer this safely. Medicines were stored and disposed of safely. Medicines were audited regularly. Stock levels of medicines were checked to ensure the expected number of medicines were left. We checked stock levels against records during the assessment and found no concerns.