Archived: St Audrey's

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 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 that people could be harmed.

The provider continued to be in breach of the legal regulation in relation to the assessment and management of risk to people. The home was clean, and some improvements had been made to the environment. People’s medicines were managed safely, and staff competency assessments were completed. Monitoring of people’s food and fluid intake and skin integrity remained in need of improvement.

This service scored 56 (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 an electronic system for incident reporting. Staff completed these and they were reviewed by the manager, who received an alert when an incident report was completed. The manager told us they ran a weekly report to check all actions were taken, to include referrals made to other organisations as required and any learning shared with staff. Most staff confirmed they were informed when incidents occurred and a relative told us, “They tend to let me know if something happens.”

We reviewed the tracker and saw examples of action taken in response to incidents.

A person had a behaviour chart which described some incidents throughout April 2025. None of these were recorded on the incident log so it was unclear what action had been taken to reduce these. The provider told us these were not considered to be incidents as they had only occurred in the person’s room with staff and were considered a means of communicating. They confirmed if the incident occurred in a communal area or affected other people they would be reported as incidents.

We reviewed the behaviour chart for this person and found it was not always completed correctly. This should include what happened before, during and after the behaviour to identify what may trigger the behaviour and what the person is trying to communicate, in order to develop strategies to reduce the occurrence. We saw it had been filled in when the person had been supported by staff and no incident had occurred. Another entry showed the before and after sections were identical. Therefore, we were not assured staff understood the purpose of the chart and were appropriately monitoring people to support them when they expressed anxiety or distress and to prevent safety incidents.

The provider 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 service had input from the GP via weekly rounds and the manager attended multidisciplinary meetings.

A professional told us, “[The manager] initiated discussion concerning the appropriate placement of 1 resident. An MDT [multi-disciplinary team meeting] was called and now further exploration including social worker, GP, day centre staff and residents' family will be meeting to discuss best outcome including type of accommodation that would be in the best interests for this resident.” This would help ensure continuity with care when people move between services.

The provider had a tracker to monitor safeguarding referrals. This included a brief summary of what happened with action taken and the date closed. At the time of our visit there were no open safeguarding concerns. Staff were trained in safeguarding. A staff member told us, “I feel safe, and I feel [the people] are safe. I can see there has been lots of improvements.”

A family member told us of a safeguarding concern involving their relative whereby they were satisfied with the action. They told us, “I was so very happy with the subsequent outcome. I saw my [relative] the day after the abuse and [relative] appeared to be not unduly concerned which was a relief.”

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

People’s food and fluid intake was not monitored well at our last inspection. Whilst we found this was better, there remained room for improvement. People’s daily fluid targets were not always met, and we saw for 1 person it had not been reported to the GP when their target was not met for 3 days, as stated in their care plan. Staff were not recording people’s food intake consistently so a healthcare professional looking at the records would be able to judge if the person had taken an adequate nutritional intake. We found some staff only recorded what was offered, some recorded they had eaten half or quarter of a meal meaning the amount actually eaten by the person was not clear. However, some staff recorded it more clearly such as the number of sandwiches eaten.

Staff management of pressure area care had also improved, but monitoring charts were not always completed to show people were supported with re-positioning as required. This meant the provider could not demonstrate the appropriate actions were being taken to prevent pressure ulcers from developing or getting worse. We noted no one had any pressure ulcers at the time of our visit and staff checked and recorded people’s skin condition. A person said, “I’m comfortable. They do come in and inspect your back and apply creams if necessary.”

Staff seemed to know people well. They gave examples of discussions with families and other professionals where they had identified needs, and new equipment had been arranged. During our visit we saw a person had a new chair, and another person had a piece of equipment on trial for support with their mobility.

The provider had not ensured the premises and equipment were well-maintained or in a suitable condition to support the delivery of safe care and to mitigate risks associated with the premises. Whilst the environment was clean, and some actions had been addressed such as securing people’s wardrobes to the walls, we found the home remained in a poor state of repair.

The kitchenette was particularly poor with a rusty microwave and rust along the edge of the fridge. This meant people were not protected against the increased risk of acquiring an infection if equipment is not in good order to enable cleaning.

The service had an overall action plan, but this did not include the refurbishment of the home. The health and safety audit detailed some actions such as decoration being required but this had a low priority score and was on hold. We discussed this with the manager who shared our concerns. They told us they had a budget for smaller items of equipment such as to buy a lawnmower to maintain the garden, but larger jobs were an issue. During our visit, a workman was on site completing some fire safety actions. However, the health and safety audit stated they were waiting on a decision for the cost of further repairs and remedial work identified in the fire risk assessment.

The provider did not always make sure all staff had the appropriate skills to meet people’s needs. New staff have been recruited to the service and the use of agency staff had reduced and the consistency of care had improved. Staff completed training such as safeguarding and infection control. Other courses included catheter care, pressure care and learning disability. However, there was no training on positive behaviour support, or some conditions people had such as diabetes, so staff had the necessary skills and knowledge to care for people safely.

Staff were assessed as competent in moving and handling and medicines administration. A staff member said, “Yes I have had the right training andsupport to meet thepeople’s needs and there is enough staff now they have recruited and got some more new staff.” We received mixed feedback from people’s relatives about staff’s skills and experiences. A relative said, “Regarding skills I think they do now. I have always been, very, very happy. Most of them have been there since my [relative] has been there.” However, a relative told us not all staff had the required skills. They said, “Some of the new ones don’t know about certain things that they should.”

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.

Managers completed quarterly infection prevention and control audits. We reviewed those for September 2024 and December 2024. In September there was a lengthy action plan which had significantly reduced by December 2024. However, when we requested the March 2025 audit this was not provided, and the infection control policy was slightly overdue for review (February 2025). The home was cleaner than we found during our last inspection. However, some of the issues with the environment, such as the kitchenette which remained in a poor state of repair, could present infection control risks.

People received their medicines as prescribed. A relative told us, “Yeah, I think it is [staff member] who manages those, [they are] on the ball. No issues.” We observed staff administer medicines to people in ways which met their needs. For example, a person’s medicines were given to them in a cup with a spoon as their dexterity varied.

People who were prescribed medicines to be given when required (PRN), had protocols for staff to refer to so they knew when and how to administer them. Staff were able to describe the guidance as we found it in the protocols and confirmed these were reviewed regularly. “MDTs are every 3 months. If we notice a change, we will inform the GP and request a review.”

Staff were able to describe the action they would take if a person refused their medicines. We were told, “In the first instance [I] would change approach, [I] would try for a while and then note on device what happened.”