St Johns 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 assessment 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.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager did not always have a proactive and positive culture of safety based on openness and honesty. Leaders did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Accidents, incidents and safeguarding concerns were largely recognised, recorded and, where required, appropriately notified, with evidence that some lessons were identified following review. However, governance systems did not always translate into consistent safe practice and drive a continuous learning culture. For example, a medication observation identified some poor infection prevention and control practice and lack of understanding of ‘as required’ medicines protocols, which had not been identified and therefore could not contribute to a learning culture.

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 were generally supported through effective systems and pathways to maintain their safety. Care records showed timely involvement of health and social care professionals, including GPs and community nursing teams, and professionals described positive communication and coordinated working with the home. Records demonstrated appropriate referrals and follow‑up where people’s needs changed. Overall, systems worked well for most people, but greater consistency was needed.

The registered manager consistently did not work to understand what being safe meant to people and how to achieve that. The registered manager did not always share concerns quickly and appropriately. While there were records demonstrating safeguarding concerns in the past had been acted upon, improvements were needed to ensure this was consistent. One person shared a serious safeguarding concern with the inspection team which had not been acted upon with robust action. This allegation had not been shared with the local authority or CQC and robust action was not taken by the service until questioned by the inspection team. An observation also highlighted a concern around someone receiving safe and dignified support whilst being supported to eat a meal. Whilst the registered manager reminded the member of staff of good practice, there was not a robust response at the time to ensure the immediate safety of people. Governance arrangements did not always provide immediate assurance safeguarding risks were escalated and acted on with sufficient urgency, limiting confidence that people were consistently protected from harm. Following the inspection, the provider responded to the risks and shared assurances to demonstrate how they were responding to the concerns to learn from these incidents.

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 involved in decisions about their care and how risks were managed. Care plans and risk assessments were detailed, person centred and reflected people’s preferences and changing needs. People and relatives said they felt safe and understood the support provided to them. Where changes were requested, such as adjustments to personal care routines, records showed these were acted on.

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 safe, clean and well maintained. The service was tidy, free from malodour and equipped with appropriate safety features. Fire safety checks, temperature monitoring and flushing of low‑use outlets were completed, and personal emergency evacuation plans were in place. Equipment and premises checks provided assurance that environmental risks were managed. People felt the home décor and cleaning was to a good standard. One person said, “It is a nice environment with lovely views.” Another person said, “They keep it nice.”

Concerns had been raised by people, relatives and staff that the service did not always make sure there were enough qualified, skilled and experienced staff and that they did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing levels on paper reflected people’s assessed dependency, but feedback from people, relatives and staff raised concerns about response times, use of agency staff and the quality of some care interactions. One person told us, “They are in and out of here like grease lightening” while another person said, “Sometimes they forget you as they can be quite busy.”

Training and supervision records showed gaps at the time of inspection, indicating staff were not always supported and monitored effectively. This was also the case where key information about agency care staff were not readily available. While actions were taken following inspection feedback, systems were not sufficiently robust to prevent these issues occurring.

We found people waited too long to receive support. Call bell response times were raised consistently by people and relatives as an issue. Leaders were not monitoring call bell response times and where people had raised this in resident meetings as an issue, action had not been taken to resolve this. People told us, “Sometimes they don’t come in of an evening, or they say they will come back and they don’t” and, “Sometimes if something happens, they get distracted. I need to press the button again.” On the second day of the inspection, we discovered staff were not carrying devices to alert them to call bells being pressed. Governance systems had not identified this as an issue nor had staff recognised the risks associated with no carrying the call bell response devices.

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 clean, hand hygiene facilities were available, and routine infection, prevention and control (IPC) audits were completed. People told us, “The home is kept nice and clean,” and “It’s absolutely clean, they are meticulous.”

The registered manager did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in medicine planning. Medicines were mostly managed safely with staff completing medication records, controlled drugs being handled appropriately, and storage and stock checks completed. However, an observed medication round identified gaps in staff knowledge of “as and when required” (PRN) medicines, particularly for people who were non‑verbal, and poor infection prevention practice. Some observed practices also showed one staff member was not infection prevention conscious which could have impacted on people’s safety. While this was not seen across all staff observations and audits showed general compliance, the issue had not been identified through routine monitoring, indicating that further work was needed to ensure consistent safe medicines practice. Following the inspection, the provider gave assurances on the action taken to ensure medication practices and infection practices around medication were consistently applied.