The Beeches (The Drive)

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

People were safeguarded from abuse. However, risks about people’s safety were not always assessed to ensure they were supported to remain as safe as possible. The provider had not ensured there were sufficient staff available to meet people's needs during night. The provider had not assessed risks of fire at night and had never conducted a nighttime fire drill. The systems for assessing people's capacity to make specific decisions was not entirely robust. People were not always able to make day to day decisions about their lives. The provider did not have an effective system in place to ensure the environment and equipment was safe. There was thorough recruitment and selection process for new staff.

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.

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.

The provider had policies and procedures in place to protect people from the risks of harm or abuse. Staff had received training about how to recognise abuse. They were able to describe the action they would take if they witnessed or suspected any abusive or neglectful practice. A staff member told us, “If someone is being abused, I would report this to my manager, if they were not here, I would report to the CQC. We have an on-call system if the manager is not picking up.” The registered manager knew what their responsibilities in protecting people from abuse and the actions they would where there was an allegation of abuse.

During our visit, we saw people were relaxed around staff. People told us they felt safe using the service. A relative commented, “I’m very happy with the home.” Another relative told us, “There has never been a time when I thought [Person] wasn’t safe.”

People were protected from the risk of abuse because the provider had taken steps to identify the possibility of abuse and prevent abuse from happening. People and relatives did not raise any concerns with us. People were able to tell us what action they would take and who they would talk to if they felt unsafe.

People were protected from avoidable harm and potential abuse. Information was made available on who to contact if people or relatives wanted to raise any concerns. The provider had a whistleblowing policy, and this gave guidance to staff on how they could raise concerns about any unsafe practice.

Systems were not always effective in assessing and managing risks to people whilst they receive a service. For example, during the visit, we identified that the risk assessment did not identify how staff would support people to leave the building in emergency if staff were lone working and people’s PEEP’s were not personalised to the individual. We identified a person received one-to-one hours linked to risks of leaving the home without staff support, and smoking risks. However, risk assessments did not fully cover the concern. Staff told us that there were restrictions around people using the kitchen when staff were supporting others, due to people touching food without washing their hands; however, risk assessments did not cover this risk. During our inspection we saw that staff were not always consistent with the support given to people. For example, a member of staff told us that the kitchen door was kept locked due to health and safety risks. However, the registered manager informed us that the kitchen door was not kept locked. The provider’s systems were not always effective. The property was not maintained well or in good condition and needed urgent maintenance, on occasions this was not completed in a reasonable timeframe. As a result, people were not being supported to live in a well-maintained living environment which impacted on their wellbeing. We found the building needed several necessary repairs to make it safe and improve the environment. We identified that on the first-floor landing there was an electrical box that had live wires clearly visible which meant that this was a potential risk to people that use the service. We were advised by staff that the electrical box had been left without a cover for approximately three weeks prior to our inspection, which concluded that the providers quality and audit checks were not effective.

The provider failed to ensure risks in relation to people's known care and support needs were adequately mitigated. Systems were not always effective in assessing and managing risks to people while they receive a service.

The registered manager told us they had processes in place for reviewing and learning from things that went wrong within the services. For example, they said, “Incident forms are completed by staff after any incidents that has happened, which is then sent to me to be reviewed and action”. Staff also confirmed that they received updates in staff meetings by the registered manager on any changes as part of lessons being learned.

We found not all people's risk assessments and management plans were robust enough to identify concerns and restrictions due to risks. For example, a person did not have a risk assessment in place around the risks relating to removing toilet rolls, which prevented other people having access to such resources when needed. We were not fully assured those systems always protected people from the risk of infection, as the provider did not always have effective systems in place to identify concerns around cleaning and ensuring people had access to toilet rolls and hand towels. People were supported by staff to receive their medicines as prescribed. However, systems did not identify that people did not have PRN (as required) medicines guidelines in place, to give staff guidance. PRN medicine should be administered 'when required', usually when the person deems, they are in need of it and often prescribed for acute or intermittent conditions and is not intended to be given as a regular dose.

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 and their families felt there were enough working at the service. A relative told us, “I think there are enough staff, with the provision (home), they have they seem to do well’. Another relative said, “Difficult to say, I think there is (enough staff) and if there were concerns over this or anything else I would be contacted. I think all of the boxes are being ticked here.”

During discussions with staff, they told us they felt supported by the management team and that they received training and induction. For example, a new member of staff said, “I am currently being supported with the induction program. I have also completed training such as safeguarding and MCA training.” Another told us “We receive regular supervision and a yearly appraisal.”

There were sufficient numbers of staff available to meet the needs of people during the day. We found there was only 1 staff member supporting 8 people during the night which could be a potential risk in the event of a fire. This was discussed with the provider and 1 extra staff member was allocated to work during the night as a sleeping staff. On the days of our visits there was a mixture of newer staff who were still within their induction periods, including well-established staff who had worked in the home for a number of years. The provider had a thorough recruitment and selection process for new staff. We saw evidence of identity checks, references being taken, and checks had been carried out with the Disclosure and Barring Service (DBS) for each staff member. The DBS helps employers to ensure people were not exposed to staff who had been barred from working with people in need of support. People received care from staff who had the knowledge and skills needed to carry out their roles and responsibilities effectively. We noted that staff had received training; however, the names of the newer staff and staff who worked occasionally were not added to the training matrix, so it was not possible to see what training they had undertaken. There were processes in place to ensure all staff received the support they needed. Staff received regular supervision and the registered manager regularly assessed and monitored the staff’s ability to meet people’s needs.

People received effective care from staff who had the knowledge and skills to carry out their job roles. Staff were supported with an induction, training, and supervision.

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