St Matthews Limited - The Avenue

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 59 (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.

The provider had systems and processes in place to record, report and investigate safety events and where required an analysis and debrief of the incident took place. For example, where a medicines error had happened an analysis of the incident had taken place and learning had been identified.

We saw that learning from incidents was discussed at team meetings. For example, at one meeting there was a discussion in relation to the management of falls, and best practice, including ensuring call bells were within reach, maintaining safe space and early escalation of concerns.

We found evidence the provider had considered the Duty of Candour regulation where applicable and had written to families to share the outcome of an investigation into concerns raised by a family.

The provider’s safeguarding lead completed a thematic review of all incidents at the service each quarter and looked at themes, contributing factors, and action required to reduce recurrence and improve outcomes for individuals and the service as a whole.

The provider did not always effectively use established systems to transition people safety during an emergency.

The provider had systems and process in place to support safe admissions and transitions to the home. For example, the provider shared their pre-admission policy and procedure, and we viewed the pre-admission assessments that were completed with people and their families before they moved into the service.

The provider shared copies of people’s personal emergency evacuation plans (PEEPs) during the assessment. We found not all PEEPs were held in the emergency evacuation bag and not all people living at the home were listed on the summary. This meant the most up to date information about people living in the home was not available in an emergency situation to aid safe transitions.

We received feedback from one relative in relation to staff not accompanying people on unplanned admissions to hospital – the relative explained this had changed since their loved one had moved into the service. We discussed this with the provider who assured us that although staff accompanying people for an unplanned admission to hospital was not part of their policy they had systems and processes in place to support safe systems, pathways and transitions. For example, there was an emergency admission pack for each person to aid a safe transition to hospital.

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.

There were safeguarding policies and procedures in place. The provider has a designated safeguarding lead who completed a quarterly analysis of all safeguarding incident and considered themes and trends.

Staff completed annual safeguarding adults and childrens training as part of their mandatory training and were able to describe how to recognise the signs of abuse and the action they would take if the suspected people were being abused.

The provider held a log of safeguarding concerns reported to the local authority and care quality commission and the registered manager was able to share investigation reports to demonstrate the process they followed to investigate allegations of abuse.
 

The provider submitted Deprivation of Liberty Safeguards (DoLS) applications and were upholding their obligations to safeguard people who had restrictive practices in place and were unable to consent to their care. Where people had a DoLS authorisation there was a supporting care plan, and where conditions had been set as part of an approved DoLS authorisation, the registered manager was able to demonstrate how steps were taken to comply with those conditions.

Although the provider did not always work well with people to understand and manage risks. Staff did provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk mitigation plans in support of their care plans and identified support needs, and although we identified a missing risk assessment for one person, we generally found risk assessments contained adequate information to meet people’s needs.

Some people living at the home required bed bumpers to protect them primarily against injury from impact against hard bed rails. During our assessment we observed that some bed bumpers had been fitted improperly and placed people at risk of harm. The registered manager assured us during the assessment learning had been shared with the team and on our subsequent visit we found bed bumpers had been adequately fitted.

We observed that not all hot water pipes in the care home had been boxed in and there was not adequate risk assessments in place in relation to this. For example, if people were at high risk of falls. The provider assured us they would take action to address this during the assessment and we found on a subsequent visit these had all been boxed in.

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

The provider had a health and safety policy in place. Regular health and safety checks were carried out by the provider or a representative acting on their behalf to ensure compliance. We found that some improvement was required to triangulate actions that had been taken in response to a failed check. For example, emergency lighting.

Staff told us that there had been changes to the environment over the last 6 months. For example, some flooring had been replaced. However, we found further improvements were required, for example, carpet replacement and broken furniture. The provider was receptive and responsive to our feedback. Some improvements commenced during our assessment. The provider shared their improvement plan demonstrating some improvements were planned prior to our assessment, and others were planned, and completed in response to our feedback.

A fire risk assessment had been completed that identified several remedial actions. The remedials had been planned, however, we were not assured that the time scale for completion were adequate. We raised this with the provider who took immediate action to address this concern and provided us with assurances the remedials were being addressed during the assessment.
 

We noted during our assessment that some rooms the provider told us would usually be locked due to risk had been left unlocked by staff. For example, the boiler room and stairs to the staff room. Although the registered manager and provider were addressing this during our assessment, more time was needed to embed this in the daily practice of the staff team.

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.

We found staff had been safely recruited in line with best practice for recruiting people employed for the purposes of carrying on a regulated activity. Staff, people and relatives we spoke with did not have any concerns in relation to staffing levels at the service and we did not find any concerns in relation to safe staffing levels during our assessment.

The provider had a dependency tool to calculate the staffing levels needed for the home. We found that rotas confirmed the identified safe staffing levels were being consistently achieved by the home. Although we did not find any concerns in relation to staffing levels during our assessment, we shared feedback with the provider about improvements to their dependency tool to ensure this was effectively calculating the required staffing levels based on need. The provider acknowledged this area for development.

The provider had a training needs analysis for the home that included mandatory and service specific training to meet people’s specific needs. For example, the provider has determined though their analysis the service required training in diabetes, dementia, dysphagia and international dysphagia diet standardisation initiative (IDDSI). A staff member told us, “There is lots of training. It’s good. We get some in-person and other training online.”

There were regular supervisions and appraisals, and staff confirmed they regularly met with a manager for supervision and annual appraisal. Staff and meeting minutes confirmed team meetings took place on a regular basis.

The provider assessed and managed the risk of infection and shared concerns with appropriate agencies promptly. However, not all bedrooms had been cleaned to the required cleanliness standard.

There were infection control policies in place and we found that regular infection control audits and checks were completed.

We found the housekeeping and laundry teams worked hard to keep the home clean. There was supporting records to assure us of daily, weekly and monthly cleaning checks being completed for all areas of the home.

We found the home was generally clean. However, we identified two people whose bedrooms required further work to improve the cleanliness. We raised this with the provider who arranged for deep cleans to take place. We found the cleanliness issues had been addressed by the end of our assessment.

Staff received infection control training as a mandatory core element of their training. Staff were observed to be using personal protective equipment (PPE) appropriately and we found there was adequate supply of this available in the home. Staff were able to demonstrate the actions they would take in response to an outbreak.

The provider 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 planning.

The provider had a medicines policy. Medicines were managed safely, and we were assured by the practices we observed during our assessment, including the management of controlled-drugs.

We found that some medicines that required an open date recording when these were commenced was not recorded. However, the provider took action to address this and shared the learning they had taken from our findings.

We found that not all ‘as required’ (PRN) medicines protocols contained sufficient guidance for staff administering medicines. We shared this feedback with the registered manager during the assessment who assured us these would be reviewed, and they would carry out a review of all other PRN medicines protocols.

Staff had received training and medicines competencies. However, we found the medicines competencies tracker was not up to date when our assessment commenced and not all annual competencies had been refreshed. The registered manager acknowledged this needed to be maintained and shared with us an updated tracker and assured us all competencies were up-to-date by the end of the assessment.