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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question Inadequate. 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 people could be harmed, however, there had been improvements in how risks and safe care were assessed and managed following the previous inspection. These improvements needed to be embedded to ensure continued and sustained improvement.

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. There was a learning culture in the organisation. Accidents and incidents were logged, reviewed and analysed on a monthly basis. The monthly analysis of data and information was used to identified lessons learned which were shared with members of staff through meetings and teaching sessions. New systems and processes, which had been developed following the previous assessment, needed to be embedded and sustained to ensure improvements were maintained.

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. People had catheter passports; however, documentation was not always kept up to date which prevented information from being shared quickly and easily. We discussed this with the management team and immediate changes were made but needed to be embedded into practice. The provider produced hospital information packs when people moved between services. The information packs contained key information about people’s needs and care updates so continuity of care and support was maintained.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to for this to be achieved. 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. The provider knew how to refer any concerns about safety or suspected abuse to the local safeguarding adults team. An analysis of safeguarding incidents was completed regularly and lessons learned were identified and shared with the staff team. The management team had a good understanding of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met. Members of staff confirmed they had accessed training to keep people safe and had access to policies and procedures to follow if they suspected abuse. One member of staff told us, “I have access to safeguarding policies in paper form in the policies folder and online too. If I suspect abuse, I will immediately raise concern to the management team and my line manager and document it, as well as [referring to] safeguarding for suspected abuse giving details of my concerns.” People who lived in the care home told us there had been improvements since our previous assessment. One person said, “[The provider] has made changes, everything feels safe here. Things are good, they are a lot better now. [Members of staff] do what you ask, before they didn’t.”

The provider worked with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. There had been improvements to the quality people’s care plans and risk assessments since the last inspection and these improvements needed to be sustained and embedded. People’s care plans and risk assessments were recorded and maintained on an electronic care planning system which enabled members of staff to capture notes and updates in ‘real time’. Whilst there had been improvements to care plans, there were, however, some areas which required further improvement including how information about loop configurations for people’s slings were recorded. There also needed to be improvements made to how information about people’s catheter care could be shared easily and effectively when people went into hospital.

The provider did not always detect and control potential risks in the care environment. They did, however, make sure equipment, facilities and technology supported the delivery of safe care. The provider had put in place appropriate systems and processes in place to monitor checks of the environment, this included routine water temperature checking and annual monitoring for water-borne infections such as Legionella. We did identify some improvements needed for the environment. These included window restrictors for 2 small top windows, general decoration of the care home and some dripping taps. When we reviewed people’s care plans we saw evidence of personal risk assessments of the care environment. Personal emergency evacuation plans (PEEPs) were in place for people who lived in the care home and were accessible to members of staff both electronically and paper-based which could be used to evacuate people in an emergency.

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 care which met people’s individual needs. There were sufficient members of staff on duty who were deployed to meet people’s needs effectively. People’s needs were met in a timely way and call bells were responded to quickly and efficiently. Recruitment of members of staff was carried out safely and the appropriate pre-employment checks were carried out. New starters accessed a comprehensive induction programme and members of staff completed a range of training courses both online and face-to-face which ensured they were able to deliver care safely. People gave us mainly positive feedback about the staff team and where there were some slight concerns, we shared this with the management team.

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. Improvements had been made to the cleanliness of the care environment following the previous inspection. The clinical infection prevention and control team had identified the need for attention to detail to cleaning practices specifically around fixtures and fittings. It was also noted not all staff were bare below the elbow. Changes and improvements needed to be sustained to ensure continued improvement.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. There had been improvements to the management of medications following the last inspection of the service. We identified some areas for improvement around how rotations of people’s pain patches were documented and recorded and how protocols for ‘as and when’ (PRN) medication explained how people would indicate they were in pain or needed their PRN medication. We raised these issues with the management team and they took immediate action and made the changes which mitigated the risk. Members of staff were able to explain the process they followed if there was a suspected medication error. A member of staff told us, “If a medicine error occurs the first priority for me is to check and ensure the resident is safe and if any harm has come to the resident. If I was in such a situation, I would report and record this error and liaise with the manager immediately, and I would get medical advice from a professional at once. I will then ensure this is communicated to all staff to prevent this error from happening again."