St Gregory's House Limited

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 because some records were not always accurate or current.

This service scored 53 (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’s systems and processes did not always capture sufficient information to allow opportunities for further investigations about safety events. Lessons were not always being learnt to continually identify and embed good practice.

An accident and incident recording system was in place. Actions taken following events were generally being recorded, including when other health professionals were called or the local authority safeguarding team informed. Records and information were collated monthly by the management team. However, the electronic records were not being used effectively meaning opportunities for reviewing actions taken and learning lessons were being missed. Where any lessons had been learned the sharing of these was done in staff handovers.

Family’s and relevant others were informed of accidents and incidents, and the duty of candour was considered.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services, such as on admission to hospital.

Preadmission assessments were not consistently recorded and those we did see did not always inform people’s care plans or risk assessments. Some people told us they had been involved in informing their care plans on admission to the service. Processes were in place to help ease transition to other services if needed such as emergency hospital admission information.

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’s systems and processes used for recording restrictive practices were not always completed in line with best practice.

Where incidents of safeguarding had been identified these had been appropriately reported to the local authority and to us. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

We found that some consents had been obtained for care and treatment and where relevant DoLS authorisations applied for. However, decisions made where people may lack capacity to do so themselves and in their best interests were not always recorded in line with best practice and the Mental Capacity Act 2005 (MCA). Historical DoLS applications had not always been reviewed regularly to ensure any changes in people’s needs had been captured. These were addressed by the management team during the inspection. Staff had completed training in recognising abuse and the MCA.

People and their relatives told us they felt the service was safe. One person told us, “I like being here because I am looked after and kept safe because of the staff.” A relative said. “[Relative] is safe with the staff here.”

The provider worked with people to understand and manage risks by thinking holistically. The provider’s systems and processes used for identifying and recording risk management was not always completed accurately or with current information. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Not all risks associated with people’s care and treatment had been recognised or recorded. Where there were records some were not accurate and/or current. The provider had systems in place for the oversight of falls, trends and themes however, it was not regularly recorded what was considered in how to minimise them. Staff could access people’s records easily to follow risk management plans.

People’s care needs were regularly being reviewed as and when needed however, some records were not always reflective of peoples’ changing needs. Staff told us they felt they had received the right training to meet people’s needs safely. We observed positive interactions by staff with people who could not easily express their needs or became distressed.

The provider did not always detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Actions required identified in the most recent independent fire risk assessment had not been evidenced as being completed in the time frame identified. The management team took immediate action to address this. Staff who worked at night were not adequately trained in fire and evacuation and the use of equipment. The management team took action and arranged for this training to be completed. Regular environment, equipment safety checks and regular servicing was in place. There was an ongoing programme of upgrading and improvements to be made in the home.

The provider needs to consider developing the design and décor of the environment to meet the needs of those living with dementia as the service has the service user band of dementia. We found the premises lacked dementia friendly signage. The provider did not follow best practice guidance to assess how each person living with dementia could orientate themselves in their surroundings. Despite providing care for a number of people with a diagnosis of dementia there was little evidence of adaptations to the environment to make it more stimulating and appropriate.

The provider did not always make sure staff employed had all the checks of suitability in place prior to employment. There were enough qualified, skilled and experienced staff who worked together well to provide care that met people’s individual needs.

The head of care had recently completed a full audit of the staff files for recruitment. This identified the actions required to ensure all the required checks of suitability to be employed had been obtained. Where we found gaps in information of suitability for some staff files, we checked these were obtained during the assessment. A checklist was included in the recruitment files however no audits check on the files were seen to have been completed previously.

There were enough suitably qualified staff on each shift. We saw induction checklists had been completed. Most training was completed via eLearning. The new management team had just commenced checking skill competencies in moving and handling, and we saw a variety of face to face training had been completed for all grades of staff. Staff told us they felt they had received sufficient training to care for people safely and felt very supported by the management team. However, we found that staff supervisions had not always been completed as regularly as per the provider’s policy and procedures.

Training records for eLearning showed some topic areas needed to be completed or refreshed. We saw induction checklists had been completed. People we spoke with thought staff were appropriately trained. One relative said, “Staff have been trained, they know how to use all the equipment.”

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. Staff and leaders worked to minimise the risk of any infection transmission.

The home was clean and regular checks of the cleanliness and infection prevention were being completed. Personal Protective Equipment (PPE) and hand sanitiser was readily available and was seen to be used effectively. People were happy with the quality of cleanliness in the home.

The provider did not make sure that medicines records supported medicines administration to safely meet people’s individual needs. The provider had not had any oversight of the safety of medicines and their administration since July.

Some records relating to the safe management of medicines needed improvement. For example, where people were receiving medicines covertly there was no care plan / risk assessment or evidence from a pharmacist that the methods used were suitable. Authorisations issued for the use of just in case medicines for end of life care had expired for 3 people.

Where high risk medicines were in use such as anticoagulants there were no risk assessments in place. Staff we spoke with were very aware of people’s medicines needs however these were not always clearly documented. We found the electronic care records system was not utilised consistently for medicines management so not all people had a care plan or risk assessments if they required them.

Audits and oversight of medicines was not recently completed in line with the provider’s policy and procedures. Audits that were in place had not captured the expiry the authorisations or where a person had lost significant weight posing a risk of being overdosed. Some issues identified by the inspection team with medicines management and records were addressed by the management team straight away.

Systems and processes to safely administer and store medicines were in place. Staff had had completed medicines training and had their competency assessed. A GP carried out a weekly ’ward round’ at the home.