Archived: The S.T.A.R. Foundation

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 requires improvement. At this assessment the rating has remained 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. The provider was in breach of legal regulation in relation to people’s safe care and treatment, and staff specific training.

This service scored 62 (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. Accidents and incidents were analysed and trends and patterns identified to mitigate future risks. The provider analysed themes and tends to improve practice.

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.

The service involved people and relatives during the transition process to ensure a smooth move between services, with effective communication. Leaders considered compatibility in referrals and assessed whether they could meet people’s needs prior to admission. Regular referral to health professionals took place which supported people to receive health care, in a timely manner.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff could identify appropriate ways to safeguard people and understood how to promptly escalate any concerns. Staff received up to date safeguarding and mental capacity training and were knowledgeable about how to keep people safe.

The provider did not always manage risks to people effectively. Staff did not consistently deliver care that met individuals’ immediate needs. For example, one person required specific positioning when eating and drinking due to known swallowing difficulties, but staff were not following this guidance, and there had been a delay in seeking further professional input. In another case, staff had not escalated concerns or shared sufficient information with relevant professionals to identify why an individual was not receiving enough fluids. This lack of action meant the person may have experienced distress that could have been avoided.

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

Maintenance checks were in place to ensure people’s safety. Staff raised any concerns directly to the management team who acted quickly to resolve any issues. Some areas of the service had been updated due to age and the home was clean, hygienic and well maintained. People’s rooms were personalised to suit their tastes, needs and preferences.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Despite staff being well trained they had not received service specific training regarding administration of medicines. They worked together well to provide safe care that met people’s individual needs. There were sufficient staff available to support people in the home and out in the community. The provider had a recruitment policy in place and pre-employment checks were in place to ensure suitable staff were recruited. New staff received a thorough induction and were supported by managers. Staff received training and support to carry out their roles effectively. One member of staff told us, "We do lots of training, some is face to face and we have a training app.”

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, and domestic staff were on shift daily to help ensure an infection free environment. Cleaning checks were in place to help monitor the cleanliness and staff wore personal protective equipment (PPE) appropriately.

The provider made sure that medicines and treatments were predominantly safe and met people’s needs, capacities, and preferences. Medicines were administered as prescribed and were safely handled and stored. However, medication stock levels were not always accurate, leading to discrepancies. Records for the application of prescribed topical medicines were not consistently signed, and some creams were not dated when opened. These issues were not identified through the provider’s medicines audits. Where medicines were prescribed on an ‘as and when required’ basis, protocols were in place to support their safe administration.

The provider did not ensure staff were appropriately trained to carry out specific tasks required for safe care. Staff had not received the necessary training to administer a prescribed medicine for epilepsy, despite this being a requirement outlined in the provider’s own policy. As a result, staff had not been assessed for competency in this area, increasing the risk of unsafe medicine administration. The registered manager took appropriate action to address this concern once highlighted.