Beacon 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

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. During our assessment of this key question, the provider failed to ensure there was effective management of identifying and assessing risks for people which resulted in a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider failed to ensure staff received up to date training, professional development, supervision and appraisal. The provider failed to ensure there were sufficient number of waking night staff to meet people’s care and treatment needs safely which resulted in a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence.

This service scored 69 (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 registered manager and deputy manager understood their roles and responsibilities relating to safeguarding and had worked with the local authority to investigate safeguarding concerns and worked with them to help keep people safe.

Staff had received training in safeguarding and were able to describe different types of abuse and knew how to raise concerns. Staff told us, “I would not hesitate to raise a safeguarding”, and “I would speak to a manager.”

People and their relatives told us they felt safe living at the Beacon House. One person said, "Yeah, I think so, I feel safe." Another person when asked if they had any concerns or worries told us, “No.” A relative told us, “Beacon House is like a second home to [Name] they are very safe, I think that is why they have improved.”

Not all risks for people had been assessed. Where a person had a serious medical condition there was no care plan or risk assessment in place to provide staff guidance of actions to be taken if the person should become unwell. Where a person regularly refused healthcare interventions by healthcare professionals, no risk assessment had been completed as to how risks were to be mitigated given their resistance and refusal. Where a person was at risk of developing pressure ulcers their care plan stated they required to be repositioned regularly. When reviewing their repositioning charts, it became apparent there was no night time repositioning being undertaken due to only 1 waking night staff present in the service. This meant there was often 12 hours between the repositioning and changing of incontinence aids placing them at potential risk of further breakdown to their skin integrity. We found a person requiring catheter care, had no information detailing the specific nature of the risk. No risk assessment had been considered relating to the potential implications and risks of having a catheter fitted, such as Urinary Tract Infections [UTI] or the catheter becoming blocked and the importance of monitoring their fluid intake and output. The deputy manager advised the fluid intake records had only been recorded for the period 1 January 2024 to 9 January 2024, however we found no entries recorded for 1 and 2 January 2024 and the remainder of the charts recorded their last drink as late afternoon. If these records were an accurate reflection of the persons fluid intake it shows they would be regularly going longer than 12 hours without a drink. Personal evacuation plans were in place for people. These provide information, for example how to safely evacuate people from the building in an event such as a fire. However, there was no information to reflect there was only 1 waking member of staff on duty at night and how risks to people were to be mitigated in such instances.

Staff we spoke to were asked about their understanding of risks relating to people using the service and were able to demonstrate this by discussing examples of people’s specific risk. For example, a person who was at risk of falls required the use of a seated walking frame when mobilising. They were supported when accessing the local community because of their mobility risk and poor awareness of road safety. Whilst they were able to describe most associated risks relating to individual people, one staff member told us they had read a person’s epilepsy care plan and risk assessment when we found one not to be in place. Another member of staff told us they were unaware of the specific actions to be taken if person should have a seizure. When speaking to the registered manager and deputy manager about a person’s catheter neither were aware as to the type of catheter the person had fitted.

During both days of inspection, we did not observe any evidence to suggest people were placed at risk or that people’s risk assessment [those in place] were not being followed. For example, a person was observed to wear long-sleeved clothing and gloves to stop them scratching, picking at their skin, and biting their hand. However. there was evidence to imply that risks relating to a person’s catheter and a person’s epilepsy were not known by staff and were not being monitored to ensure their safety. Additionally, records evidenced a person was not being repositioned in line with their care plan therefore were at continued risk of their pressure ulcers deteriorating further.

Due to unforeseen circumstances regarding a flood occurring at the service, this resulted in a person having to relocate bedrooms for an interim period until essential works had been carried out. The person understood the risk to themselves and their safety if they remained in their bedroom. They consented to move rooms until essential works were completed.

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

Staff recruitment files reviewed for 2 members of staff found appropriate checks had been completed before a new member of staff commenced working at the service. This included an application form, exploration of employment history and gaps in employment, written references, proof of identification and Disclosure and Barring Service [DBS] checks. Staff had received an induction. However, we found not all staff had completed the Care Certificate within a reasonable timeframe, this being 12 weeks. For example, one staff member according to the registered manager had only just completed the Care Certificate but had commenced in post on 25 July 2023. Not all staff employed at the service had attained up to date mandatory or specialist training relating to the needs of the people they supported. This also referred to medicines training and competency assessments. Other than the management team, no staff were aware of Right Support, Right Care, Right Culture. Training records showed that not all staff had received training to enable them to carry out their duties when supporting autistic people and people with a learning disability. The registered manager told us they would be enrolling staff in further training when it became available. While staff told us they felt supported, staff had not received regular formal supervision in line with the providers expectations. The registered manager stated staff were expected to receive 4 formal supervisions per annum. Staff files for 2 members of staff employed longer than 12 months were also viewed. The records showed evidence of either no formal supervision having been undertaken and for 1 member of staff their last supervision was back in June 2023. Neither member of staff had evidence of having received an annual appraisal in the last 12 months.

There were enough staff on duty during both days of inspection in line with staffing levels. People were observed to have their 1-1 staff as stated. People using the service received support as needed and required. We were not assured there were sufficient waking night staff on duty to meet people’s needs, particularly if they became anxious or distressed if the event of an emergency situation occurring and be able to support people safely. For a person at risk of developing pressure ulcers, preventative measures such as regular repositioning and changing of incontinence aids required to be undertaken by 2 members of staff were unable to be carried out due to the service only having 1 waking member of night staff on duty.

People and their relatives told us there were enough staff to meet their needs. One person told us, “There are always staff present at Beacon House,” and was aware there were both permanent and agency staff deployed to the service. One relative said, “there seem to be enough staff, although I do not think they do much with [Name], they appear to be kind.”

The Care Coordinator confirmed on the first day of inspection the staffing levels at the service. This was also confirmed as accurate by the registered manager. Two staff spoken with on the second day of inspection confirmed the staffing levels at the service. The registered manager advised there is an on-call system in place, and this is shared between 6 people [management team and 2 team leaders] and this is rotated 3 days on and off. The registered manager told us they were currently recruiting and have recruited 1 full time member of staff who is due to commence in post. The service uses regular agency staff at the moment to support with sickness and gaps in the rota. People who use the service received allocated 1-1 staffing throughout the day. The Care Coordinator stated the 1-1 hours are for personal care, enabling people to access the community and attendance with healthcare appointments and assistance with daily living tasks.

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.

The registered manager confirmed the number of staff administering medicines to people using the service. We found not all staff had up to date medicines training and competencies in place. The deputy manager advised staff competency checks should be carried out annually, however we found of the 7 staff administering medicines to people, 4 had no competency assessments in place, 1 had their last competency assessment undertaken in January 2022 and 2 staff required either additional support or training which could not be evidenced at the time of our assessment.

The Medicines Administration Records [MAR] for each person were viewed for the period 8 January 2024 to 4 February 2024 inclusive. Each person had a medication profile detailing allergies and their preferred method for taking their medicines, for example, from the pot with a glass of water or their medicines being placed on a spoon. There were no unexplained gaps noted on the MAR forms. PRN protocols in place for ‘as required’ medicines were signed by the GP. We found no evidence for people who could be distressed and anxious and who required medicines to manage their behaviours were being inappropriately controlled by these. People’s medicine counts reconciled when checked, and records showed people received periodic medication reviews by the GP and/or consultant psychiatrist. Regular monthly auditing of people’s medicines had been carried out and actions taken when required.

People we spoke with confirmed they received their medicines as they should. However, 1 person told us staff who administered their morning medicines, often woke them up too early and they did not like this. During the inspection the person relayed this information to the deputy manager, the deputy manager was asked by the inspector to review this with the persons GP at the earliest opportunity.