Anchor House - Doncaster

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding and the way people’s medicines were managed safely.
 

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. There was no evidence of a learning culture or learning from accidents and incidents in the care home. Systems and processes were not in place to analyse and review accidents or incidents where people fell or injured themselves. There was not a system in place to provide feedback to the staff team about how to mitigate the risk of future accidents and incidents. Accidents and incidents were not always reported to CQC through the use of notifications.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. There was limited information in care plans which could be shared between care services to ensure an effective transfer between services. Care plans required improvement to ensure they were up to date and accurately reflected people’s needs.

The provider 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. The provider did not always share concerns quickly and appropriately. Safeguarding incidents were not reported to the local safeguarding adults team in a timely manner and there was no evidence of analysis of safeguarding referrals or identification of lessons learned from safeguarding incidents. Safeguarding incidents were not always reported to CQC through the use of notifications.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans were poorly maintained and contained brief information about people and their care needs. There was limited detail or information which would enable a new member of staff to know and understand people’s needs and how to care for them. Care could not be provided in line with people’s care plans because they did not contain sufficiently detailed information about how care should be provided. There was no evidence people were involved in developing their care plans or risk assessments.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. There was no evidence of risk assessments and checks carried out on the water systems. This is a risk to service users, staff and visitors because the primary method used to control the risk from legionella is water temperature control. There was poor record keeping of environmental checks and risk assessments. The gas boiler and hot water tank cupboards were found to be unlocked in downstairs shower room. This was a risk to people and staff.

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 which met people’s individual needs. There was no interaction between staff and people who were sat in the lounge areas. Staff were task-focussed and not deployed effectively. Members of staff did not support people to engage in meaningful conversations or stimulating activities. There was limited evidence of management-led supervision sessions for staff where areas for development and improvement in the quality of care and support could be discussed.

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. Many areas in the care home were poorly maintained. Some armchairs in the lounge were dirty and in need of deep cleaning. Used crockery and cutlery was washed in a sink in the kitchenette and not sterilised. Members of staff used tea towels to dry their hands and then dried the washed crockery and cutlery. These practices increased the risk of cross infection.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning about how they received their medicines safely. Medicines were not managed safely. Protocols for ‘as and when’ (PRN) medication were not in place for everyone who lived in the care home. Where people had PRN medication prescribed, medication administration records indicated it was given regularly and at specific times. Some people required medicated topical creams but there was no evidence of body maps to show where creams should be applied and where creams had been applied.