Bethrey 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

The service was not safe. We identified 3 breaches of the legal regulations. People did not always receive safe care as care plans were not always in place, reviewed or followed. Incidents were not always identified and actioned, which resulted in the home not having a positive learning culture. Safeguarding concerns were not always followed to ensure people were protected from potential abuse. There were concerns with the environment and the measures in place to ensure it was clean. Medicines were not stored safely to ensure people were protected from the risk of harm. There were enough staff available for people. However they did not always have the skills, knowledge and training to safely support people and were not always safely recruited.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives raised no concerns around the learning culture within the home. However, when asked they were unable to tell us what this meant or how they were involved with this.

The nominated individual told us they had implemented an accident book so that all incidents could be recorded, they could then use this information to show how they were learning from this. All staff were unable to explain this process to us or state how they were involved with this.

The systems in place were not effective to ensure people were safe. When incidents had occurred, these were not always recorded, investigated or reviewed to identify any learning. The provider was not always aware when incidents had occurred. For example, when people had bruises or had fallen, we could not always see that these incidents were monitored to ensure learning from them.

People and relatives raised no direct concerns with this, however when asked people were not aware of their assessments or if they had care plans in place. When we asked a person if they had a care plan in place they told us that they didn’t and didn’t know what one was.

The nominated individual told us there were process in place to ensure people were assessed before they started using the service. They told us the registered manager, who was currently absent from the home, had been responsible for this. When asked they were unable to share what the process was. Staff were not always aware of the assessment processes used at the service.

As part of this assessment, we asked for feedback from the local authority. They told us they had recently visited Bethrey House and found concerns. They had worked with the provider to put in place an action plan which they shared with us. The local authority found concerns relating to people’s safety, including where a person had lost weight and how prescribed items were stored.

People did not always have copies of assessments in place, so it was unclear what their needs were and if care plans and risk assessments were based on these needs. When people had individual needs there were not always care plans, risk assessments or guidance in place for staff to follow. This placed people at risk of receiving unsafe and/or unsuitable care.

People and relatives raised no concerns about safety. One person told us they had never felt mistreated but if they did, they would go to the manager.

Staff were unable to demonstrate to us what safeguarding or safeguarding procedures were. One staff member said, “It’s when you manual handle people”. Another said, “Its personal care and doing it safely.” Staff we spoke with told us they had not always received training or up to date training in this area. The nominated individual told us there were safeguarding procedures in place that were followed, however provided no further details.

During our site visit we observed people were not supported to transfer using the correct moving and handling techniques, this included being supported under their arms. This placed people at risk of injury. We also saw a person was seated in a chair with their feet upright and they could not independently move from this position. The walking aid they used was located on the other side of the room and the provider had not considered this was restrictive practice

There were procedures in place to identify and report safeguarding concerns, however these were not followed. We saw a body map where 1 person had unexplained bruising. No investigation had taken place, and this had not been reported as a safeguarding concern. The nominated individual was unaware of this. After our assessment we told the nominated individual to raise the safeguarding concerns we identified during our assessment as they had not done so, the action the nominated individual took demonstrated they did not understand this process and they did not complete this in a timely manner. When needed we saw Deprivation of Liberty Safeguards (DoLS) were in place, for people, however we could be assured these were up to date as care was not reviewed when changes occurred.

We received mixed feedback from people with how their risks were managed. In reference to having a call bell in their room 1 person told us, “I haven’t got 1. I’d have to open the door and shout. What if I was ill?”. Staff confirmed this person required a call bell. However, this was not available to them at the time of our site visit. Another person told us, “I respect them, and they respect me. They have to be well-trained, especially with the dementia patients. I’ve always felt confident that they know what they are doing.”

Staff and leaders were not always aware of people’s risks and how to support people safely. Staff we spoke with told us they were not always aware of what was contained in some people’s care plans. For example, the equipment they used when mobilising.

During our site visit we saw people were not always supported in line with their care plans or risk assessments. For example, 1 person transferred with the use of a walking aid they had not been assessed to use. Another person was not supervised when mobilising in line with the guidance in their care plan. Other people were not always safely transferred using safe moving and positioning techniques. People did not always receive support with health conditions when they requested this. This placed people at risk of harm.

The processes in place to manage risk were not effective. Care plans were not always in place, reviewed or monitored. There was no system in place to update, change or add care plans when people’s needs changed. There was no oversight in place to monitor and review incidents that occurred within the home. There were no audits in place that monitored the care and support people received.

People raised concerns to us about the environment. One person said, “I want to go home, this place isn't homely." One person referred to the dining room/lounge as ‘crowded’ and another person referred negatively to everyone being ‘packed in’ the same area.

The nominated individual referred to the home as needing “Tender loving care” (TLC). They told us they wanted to make improvements and had identified areas where these could be made. Staff raised concerns with the environment and the lack of space people had to access, including the lounge, lack of dining area and garden.

We saw areas of the home that needed repair, for example the gate on the stairs was not fully functional, it required several attempts for it to lock securely. There was a ramp in the downstairs corridor that was uneven, this was not identified as a risk. The lock on the door at the top of the stairs was not working, we had to ask a staff member to resolve this. A mobile ramp was used by staff for people to access various parts of the home, when they were mobile or using a wheelchair, meaning people could not safely access all areas of their home without the support of staff.

Effective systems were not always in place to monitor the environment. The concerns we identified through our observations had not been actioned. We saw hoists and electrical equipment that had out of date safety checks. During our site visit here was no effective system in place that could demonstrate if safety checks on this equipment had been completed.

People and relatives raised no concerns about the number of staff available. One person said, “Staff come quickly” and that they had never waited.

Staff told us they had not always had training or received up to date training, one staff member told us they had not received any training since starting employment at the home. Other staff confirmed they had not received up to date training in food hygiene, safeguarding and management of behaviours. Staff we spoke with confirmed they had not had competency checks completed in key areas such as safeguarding and moving and handling. Both staff and leaders felt there were enough staff available for people. However, the nominated individual confirmed there were no systems or effective tools in place to work out how many staff were needed. They told us they used an excel spread sheet the home had created. They did not reference how this tool worked and if it was based on the numbers of people or the dependency of individuals.

We observed staff did not always have the skills, knowledge or training to support people in a safe way. For example, staff did not support people to transfer safely by using the correct moving and handling techniques or equipment. We also saw people who were completing odd jobs at the service, accessing the home without the relevant checks to do so. On the day of our site visit we saw there was enough staff available for people. There was a staff member available in the lounge to support people when needed.

There was no effective system in place to ensure there were enough staff available for people. On the day of our site visit we saw there was enough staff, however there were more staff on shift than recorded on the rota and the nominated individual told us was required. Staff had not always received training to ensure they had the skills and knowledge to support people. This included moving and handling, safeguarding and food hygiene training. When staff had received training there was no evidence to show they had their competency checked. There was no training matrix in place for us to review. When asked if staff had received training, we were presented with a large folder with staff certificates in which dated back to 2018, there was no oversight of this to identify if staff training was up to date. The certificates we reviewed confirmed it was not. Staff had not always received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so. We saw some staff did not have a record of their DBS number on file and other staff had this completed by previous employees. People who were regularly at the home and could be considered as volunteers had no checks completed. There was an agency staff member who had started at the home the day before our site visit, we asked to see their induction which was blank and they confirmed they had not received one.

People and relatives raised no concerns about the cleanliness of the home.

When asked how infection control was monitored in the home, the nominated individual told us “It should be in the files in the office”. They told us they were aware various areas of the home were in need of repair and they had plans in place to work through this. However, they confirmed when asked that there were no recorded action plans in place that addressed how and when these repairs would take place. Staff told us they had personal protective equipment available to them.

The home was not always clean, we saw there was dust on skirting boards and in high places. Two peddle bins in the home were broken which increased the risk of cross infection as you had to use your hands to open them. Areas of the home needing sweeping including the kitchen floor where meals were being prepared.

Effective systems were not in place to monitor IPC, the concerns we identified through our observations had not been identified or actioned by the provider. There was no audit completed in the home relating to infection prevention control.

People raised no concerns with how their medicines were administered. One person said, “I get my tablets at the right time and don’t have any anxiety about that”. Another person commented, “There seems to be a lot of changes over who does the medications trolley, but they seem to know what they're doing.”

When we discussed the medicines processes with the nominated individual, they were not always aware what these were and had to rely on staff to tell us. They told us they had identified concerns with medicines and had discussed these with the GP. We spoke with the staff member completing medicines, they could not confidently share the process for how they administered medicines.

We found concerns with the storage of medicines. The room was not suitable as it was small and not secure. There was no monitoring of the room temperature, despite the local authority raising this with the nominated individual. When people had ‘as required’ medicines the protocols in place lacked detail and staff were not recording why people had needed these. We found a medicine that had been cut in half by staff was stored in a clear plastic bag with no details on, placing people at risk of receiving the incorrect medicines.