Ancasta Grove

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 assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and accidents were reported, investigated and lessons learned were shared with staff. Incidents were analysed to identify any trends and actions identified were completed. For example, a review of equipment in use took place for one person who had fallen, and we saw people had been referred to the falls team where appropriate.

We saw that records of lessons learned were available for staff to read. Staff told us they were kept informed. One staff member said, “We have a secure messaging system, we get told during meetings, we get sent emails and we have the daily meeting. There is a no blame culture here; things happen and can happen to anyone. We have to deal with it, learn from it and make sure it doesn’t happen again.”

Serious incidents were also shared across the provider’s other services, and we saw examples of these on display in staff only areas.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s care and support plans were regularly reviewed to ensure they remained reflective of people’s needs. This meant staff were able to provide up to date information to healthcare partners when people’s needs changed.

We saw records that showed people were referred to other health professionals for advice when required. Health professionals told us the staff team were consistently proactive in seeking professional advice and support from the local practice teams and the home visiting service, which provided both planned and reactive care. They told us, “This collaborative approach ensures people receive timely, safe, and well‑coordinated care.”

When people became unwell and concerns were escalated to external health professionals, records showed staff included comprehensive information to be reviewed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at the service. For example, one person told us, “Yes, I feel safe personally.” All relatives we spoke with told us they felt confident their loved one was safe. One person’s relative said, “Yes absolutely safe. The staff are very attentive and provide great care.”

Staff had been trained in safeguarding and understood their responsibilities in reporting safeguarding concerns. One staff member said, “We do the training every year. It’s to protect the residents from any abuse or anything that can harm them. We protect the residents and look after them. We make them feel safe because this is their home.”

There were safeguarding and whistleblowing procedures in place. The management team understood their responsibilities regarding any action needed to protect people from harm. The necessary internal documentation was completed including accident and incidents logs and body maps. The provider ensured referrals and notifications were made to both the local authority and the Care Quality Commission in a timely manner.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were assessed for risks such as skin damage, malnutrition, falls and choking. When risks were identified, care plans provided guidance for staff on how to reduce the risks. For example, some people were at risk of skin breakdown, and the care plans we reviewed included information such as any pressure relieving equipment in use, how often staff needed to support people to change position, and how to monitor for skin damage. Pressure relieving equipment we looked at was set correctly and records showed people were supported to change position in accordance with care plan guidance. Staff were knowledgeable about people’s skin integrity needs. One staff member said, “It’s always written on their chart. We must follow what their care plan says and what’s said during handover. We apply creams and if we find any redness or concerns, we report it to the nurse and document it.”

Some people had been assessed as a high risk of falling. People’s relatives told us staff had discussed the risk with them and taken steps to keep people safe. For example, one person’s relative said, “[Name] is at risk of rolling from the bed, so the staff have put the bed low to the ground with a soft mat at the side of the bed. The staff discussed it with us first and I thought it was a good idea.” Staff we spoke with knew which people were at risk of falling and the safety measures in place. All staff knew what steps they should take in the event of someone falling.

Care plans for people who were at risk of choking were detailed and informed staff how to reduce the risk. There was step by step guidance recorded on what to do in the event of a choking episode. Staff knew which people were at risk and knew how to reduce the risks by ensuring people were positioned correctly, following dietary guidance and using small utensils during meals.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was visibly clean and well maintained. Staff were able to report any maintenance requirements. Equipment that we looked at was fit for purpose. For example, wheelchairs and moving and handling equipment were in good condition and visibly clean.

There was a well-maintained secure garden area for people to use during warmer weather.

We reviewed records of checks carried out to ensure the premises were safe. This included gas, electrical and fire safety checks. Regular checks of equipment were carried out. Personal evacuation plans were in place. These had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service used a dependency tool to calculate staffing levels based on people’s care and support needs. The staff rota showed that staffing levels were maintained. Although most people felt there were enough staff on duty, some told us they believed the staff were busy and sometimes took a while to respond to call bells. People’s relatives also told us they felt there were generally enough staff on duty most of the time. During the inspection we observed that call bells were answered in a timely manner. The service audited response times to call bell alerts to help ensure that appropriate numbers of staff were in place at key times of the day. We found that staff were visible and were not rushing, and we saw that staff took the time to sit and talk with people.

Safe recruitment processes were followed. Staff told us they had regular supervisions and were trained to carry out their roles. Training records showed a high compliance of staff training. Staff told us additional training was available to support them to develop personally and professionally, and nurses told us they had access to additional clinical training in order to maintain their professional registration requirements. One staff member said, “[Provider] provides lots of training, probably equal to opportunities in the NHS, including management courses etc. From a revalidation point of view, I am fine. I'm having training provided locally to me so as a team we can access that as well.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was visibly clean and well maintained. People told us they were happy with the cleanliness. One person said, “It’s like a hotel here.” People’s relatives told us they felt the service was kept clean. Housekeeping staff were on duty seven days a week. Cleaning chemicals were safely locked away when not in use by staff. Cleaning schedules for equipment used by staff were in place and these included moving and handling equipment and mattresses in people’s bedrooms. Regular cleaning of touch points took place.

Staff had been trained in infection prevention and control and knew when and how to apply personal protective equipment (PPE) and when and how to safely discard it after use. There was enough PPE available for staff to use.

Regular infection prevention control audits had been carried out, including staff hand hygiene audits.

The registered manager maintained an oversight of any infections at the service, including any prescribed treatments and these were reviewed during weekly clinical meetings.

In the main, medicines were managed safely, however, there were some areas where improvements were needed. Some people were prescribed medicines on an as required (PRN) basis. We found some examples where PRN protocols were not always personalised or sufficiently detailed. When PRN medicines had been administered, staff had documented the reasons why and the effectiveness. However, the information recorded in relation to the effectiveness was not always informative. For example, in one person’s records staff had documented “somewhat effective”, but there was no full description. This meant it might be difficult for staff to assess if the use of PRN’s was effective or if they needed reviewing by a GP. Despite this, records showed that people had their medicines regularly reviewed.

Medicines were stored safely. However, we saw some personal items were stored in a locked cupboard in one medicine room, which were not labelled. Personal items such as these should be stored securely, but storage of such items in a medicines cupboard was not in line with the provider’s policy. The registered manager told us they would investigate this. This had not been identified during audits.

We saw that when a medicines incident was identified, the management team responded quickly and were open and transparent with all involved, including people and their relatives and the GP. We were provided with information about steps taken to prevent a recurrence as well as assurances that no person had come to any harm.

Some people had chosen to manage their own medicines. Assessments had been carried out to ensure people knew what their medicines were for, when to take them and how to keep them secure. We saw that people kept these locked away safely and that staff monitored stock levels to check there were no issues. Some people were prescribed time specific medicines for a health condition. Records showed these medicines were consistently given on time.

Staff had been trained and had their competence regularly assessed. Regular audits and safety checks were carried out. People had regular medicine reviews with external health professionals. One person’s relative said, “The nurses are really on it with [name’s] medicines. They have been working out the best dose of pain relief. It’s spot on now; [name] is pain free but awake during the day now and calm.”