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 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 legal regulation in relation to people’s safe care and treatment, infection prevention and control, and the way people’s medicines were managed at the service.

This service scored 38 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The provider was not able to evidence records and analyses of accidents, incidents and lessons learned over the previous 12 months. The new management team had implemented a system of recording and reviewing accidents and incidents. A culture of learning and improvement needed to be embedded throughout the care home.

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. The service was only able to accept new placements for residential care once their assessments had been reviewed by the local social care professionals to ensure their needs could be met. Recent pre-admission assessments had been rejected by local social care professionals because the provider was unable to meet people’s needs safely. The provider’s electronic care planning system had the facility to create a hospital information pack so people’s care plans and notes could be shared with health and care professionals when required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve for this to be achieved. Staff supported people to live free from bullying, harassment, abuse and discrimination. Processes were in place to make safeguarding referrals to the Local Authority. People’s care plans included information about people’s mental capacity and ability to make decisions. Where decisions needed to be made, these were recorded appropriately and decisions were made in people’s best interest. We saw evidence the provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. 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.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care plans and risk assessment were detailed, however, the care and support delivered did not reflect them which put people at risk. Risks associated with equipment used to service meals were not identified or mitigated effectively. Members of staff were not aware of specific risks and mitigations associated with people’s specific clinical guidance in relation to how they should be supported to eat and drink safely. This put people at risk. People with pressure care needs had specialist mattresses in place, however, all of these mattresses were indicating an error, and the provider and management team had not taken action to rectify these errors. We asked the provider and management team to take immediate action to keep people safe.

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. The external and internal environments of the care home were not maintained safely. This put people at risk. The outside garden area was littered with waste items including wood, old equipment, containers of old cooking oil and items waiting for disposal. A water overflow pipe was pouring water constantly into the garden area causing a noise hazard for the person who lived in the room directly beneath the overflow pipe. People’s washing was hanging on lines in between the waste build up and clothes were touching the floor, and some items had fallen onto the ground. Storage areas inside the care home were also cluttered and we saw examples where food items were stored alongside archive materials and cleaning products. This put people at risk. Boiler and electrical cupboards were not always locked which put people at risk. We raised these issues with the provider and the management team.

The provider did not 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 work together well to provide safe care which met people’s individual needs. There were insufficient numbers of staff on duty to meet people’s needs and those members of staff who were on duty were not deployed effectively. The management team used a dependency tool which was solely based on care needs and not the layout of the building or people’s preferences such as activities and social stimulation. The last completed dependency tool was dated July 2026 and did not reflect the needs or support requirements of people at the time of this inspection. For example, a person’s care plan identified they wanted to go in the garden area and another person, who was cared for in bed, wanted some 1-1 time and support but these care and support requirements could not be provided due to the minimal number of staff available on shift.

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. Cleaning and disinfection processes were not effective. We saw toilets, bath hoists and furniture which were not clean. Soiled continence products were not disposed of correctly and in accordance with expected standards of infection prevention and control practices. This meant people were not protected from the risk and spread of infection.

The provider did not make sure the management of medicines and treatments was safe and met people’s needs, capacities and preferences. People were not involved in planning to receive their medicines safely. Protocols for people’s ‘as and when’ pain relief medication were not sufficiently detailed and did not contain information about how people might present if they were in pain and needed pain relief. The administration of controlled drugs was recorded in a controlled drugs book; however, not all administrations of controlled drugs had been signed by 2 members of staff. One person’s medication had run out 4 days before the date of our site visit to the care home. There had been no action taken to order a new prescription, so the person had missed their medication for 4 days. We asked the provider to take immediate action. The administration of medicines was not managed safely which put people at risk of harm.