Archived: Sitara Haven

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 changed to inadequate.

This meant people were not safe and were at risk of avoidable harm. The service was in breach of the legal regulations in relation to staffing, people being safeguarded from abuse, the suitability and safety of the environment and safe care and treatment.

The provider had not ensured that people’s medicines were managed safely and the cleanliness of the service was maintained.

This service scored 34 (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 did not always have a proactive and positive culture of safety. Staff did not always listen to concerns and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We were not assured that the provider had taken the opportunity to learn from the findings of the last inspection in June 2022 in relation to safe care and treatment, to make improvements to the quality and safety of the service. For example, risk assessments were still lacking details and had not addressed the risks to people and safe medicines practices were not always followed.

The provider had some staff meetings but did not have daily handovers or any other identified processes to review people’s care, and to discuss accidents, incidents, complaints, or other adverse events and to learn from these.

Notwithstanding the above, the provider notified CQC of events when it was required to do so.

The service 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 provider had hospital passports to use when people are transferred to other healthcare services. This ensured other health and care professionals have the necessary information when caring for people

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately. The systems and arrangements in place for the management of people’s finances were not transparent enough to demonstrate that people were protected from the risk of financial abuse. Clear records and associated receipts for expenses were not always maintained to confirm how people’s money was being spent and managed.

The provider did not have team meetings or any means of communication to discuss safeguarding and their responsibilities to people they supported. This meant that staff did not have the space to discuss and reflect on how best to protect people from the risk of harm, abuse and neglect.

The provider did not follow secure processes to ensure only vetted people had access to the home. On the day of the inspection the doorbell to the home was not working, when staff answered the door, we explained who we were and why we were here, the staff member did not check our identification or ask us to sign in.

The person living in the home had a Dols (Deprivation of Liberty Safeguards) authorisation in place this was renewed as required. Although we identified the concerns above the staff undertook training to understand their role in safeguarding adults.

At our last assessment we identified that risks to people’s health and wellbeing had not been identified and mitigated, at this assessment while there have been some improvements, these were still lacking to fully address risks to people in a way that promoted people’s independence and inclusion.

Notwithstanding the above people’s physical and mental health were reviewed and professional support sought when required.

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

Safety checks including fire, electrical and gas checks were carried out to ensure equipment was safe for use. However, health and safety checks were ineffective as they failed to identify the issues in relation to the premises which left people in an environment which was not safe and clean.

The provider could not also demonstrate that the home and the communal areas were decorated and maintained according to people’s needs and preferences. During the visit we observed that communal areas in the home were decorated without the involvement of people using the service and in a way that did not reflect their needs.

A radiator cover had partly come off in a person’s bedroom; the provider showed us they had taken it off to allow heat to come through. This meant if the person had a fall near the radiator, they were not protected from a possible burn or injury. Whilst we were present the provider put the piece of wood back on the radiator.

The provider did not always make sure there were enough qualified, skilled and experienced staff. 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.

The provider did not have a rota in place, whilst they explained that staff had the same shifts weekly, there was no record of the hours staff worked. This meant there were no formal records of the staff who supported the person with their care, should this information be required such as if there was an incident. This also meant the person supported did not know who was working on the day. Although there were records that staff supervisions were taking place, we could not be assured these were independent enough and that these were effective as we identified shortfalls in the quality of care being provided, that had not been identified, discussed or addressed. The provider had not ensured staff were competent in their roles.

Notwithstanding the above medicines administration competency checks had been completed to demonstrate staff competency.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection control practices were poor and pose a risk to people’s health.

The provider told us that the kitchen had been cleaned one week prior to our inspection visit by a professional cleaner, however this was not evident. We found that the kitchen was not maintained to a satisfactory standard of cleanliness. For example, we saw the cooker vents and hood were covered in grease and the oven was dirty and had a pan of used oil in it.

The fridge and freezer were dirty and had a number of prepared food containers, and green salad. There were no labels for opening dates or contents. The freezer had unlabelled food. This posed a risk to the safety of people and increased the spread of infections.

There were a number of pets living in the home. We observed them to be eating form tables and countertops form their food bowls and saw soiled floorings in the corner of the lounge. This meant people could be at risk of harm from cross contamination due to poor hygiene practices.

The downstairs toilet and shower were clean but had black mould around the shower area that needed treatment. There were no hand towels to dry hands after handwashing. A box of tissues was placed there after we had raised this concern with the provider. This meant that people could be put at risk of harm due to a lack of adequate infection control and prevention measures.

Health and safety audits were in place. However, they had not identified the concerns we saw during our inspection. The lack of effective review and auditing tools did not ensure improvements could be made or learning could be shared widely across the staff team.

Staff training for food hygiene was up to date; however the above shortfalls did not reflect training completed was effective.

Medicines and treatments were not consistently managed in a way that ensured safety or aligned with individuals’ needs, capacities, and preferences. People were not actively involved in planning their care. We found that staff had not always signed the medicines record (MAR chart), when administering medicines. Whilst we could see one of the medicines was administered and not signed for, the others from previous months which we could not check if they were administered or not. A repeat prescription for another medicine to be administered monthly was not supplied by the pharmacy, this meant that it was not administered for 2 months.

The provider had not followed their own policy; they had handwritten in pencil at the end of the MAR chart that they had contacted the pharmacy. However, this was not followed up. The provider had no further written communication on an update and outcome to resolve this matter. Medicine audits were in place but just to count medicines, there was no audit to check medicines coming into the home. Whilst the provider said they checked signing of medicine sheets; they had failed to identify the errors we found on the day of our visit. Whilst staff received training in medicines management, this was not effective in ensuring medicines were always administered safely and as prescribed.