St Dominics Residential Home

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 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 did not always demonstrate a proactive approach to monitoring and learning from safety incidents in order to embed good practice. Systems were in place for recording individual incidents and accidents and the provider had implemented monthly falls analysis. However, they were not able to evidence how other incidents were monitored to identify trends and themes. For example, incidents where people were experiencing distress. Documentation was not always in place to evidence the actions taken following safeguarding concerns and this meant it was not always clear whether any learning had been identified to improve practices and mitigate the risk of future incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people came into the service for respite care and when they were admitted and discharged from hospital. The provider liaised with relevant health professionals to ensure people’s transitions were managed safely.

The provider had not always ensured safeguarding processes had been implemented effectively. Whilst we found the provider had notified the local authority of safeguarding concerns appropriately, we found some safeguarding concerns had not been reported to CQC in line with the provider’s regulatory responsibilities. The provider’s overview of safeguarding documentation lacked detail and information was not held together or easily accessed for review. This meant it was difficult to check whether appropriate actions had been taken. Following our feedback, the provider responded promptly, submitting retrospective notifications and reviewing their safeguarding recording processes.

The provider had a safeguarding policy in place for staff to follow and people and those important to them were given information about how to raise concerns. Relatives told us they were confident any concerns would be addressed promptly.

The provider had not always clearly documented risks to people’s safety to ensure staff had information about how to support people appropriately. Risk assessments were not in place for all identified risks. Where risk assessments were in place, we found some lacked detail or had not been updated to reflect people’s current needs. For example, we found conflicting and out of date information in relation to people’s current nutritional support needs and related choking risks.

We received some mixed feedback from people’s relatives about the understanding and management of risks for people experiencing distress, who may pose a risk to themselves or others. Personalised risk assessments regarding people’s support when distressed were not in place to provide detailed guidance on what actions staff should take to minimise risks.

At the time of the inspection, the provider was in the process of transferring information onto a new electronic care planning system and they told us some specific templates for risk assessments were not yet operational. Following our feedback, managers confirmed all risk assessments relating to people’s nutritional needs and choking risks had been reviewed and all out of date or inaccurate information removed. They told us they were also in the process of amending the electronic system to ensure specialised templates were in place for all risks.

Whilst we identified concerns with documentation, we also found people were supported by a consistent staff team who knew them well and understood the risks related to their health and safety needs. All relatives we spoke to felt people were safe and people confirmed they felt safe. Comments included, “I felt very safe”, “[Person] is safe. They monitor and make sure [person] is not walking around on their own. [Person] has a wheelchair or walking stick if needed” and “You can’t prevent every accident, [person] is as safe as they can be.”

The provider was not always able to evidence how they assessed and mitigated potential risks in the care environment. During the inspection, we found an upstairs window where the window restrictors had been removed to decorate. However, they had not been replaced following decoration. The provider had not identified this risk through their own risk management processes. Following our feedback, the provider amended their room safety checklists and put extra safety checks in place for periods of redecoration.

During the inspection we identified potential hazards relating to items stored within the service, the open access to the stairs, and the security of the grounds. The provider told us the layout and style of the service were considered when completing initial assessments of people’s needs and they would not offer a place to any person if the service was not suitable for their needs. However, the provider was not able to evidence any personalised risk assessments for people currently living in the service to demonstrate how these potential hazards had been considered and assessed. Following the inspection, the provider confirmed they were reviewing people’s individual risk assessments to ensure this information was included.

The provider made sure there were enough staff available to meet people’s needs and preferences. Staff knew people well and understood how they liked to be supported.

Processes were in place to provide staff with relevant training and supervision to meet the requirements of their role. However, at the time of the inspection, the provider’s records evidenced some staff training and supervisions were overdue. The provider confirmed they had identified which staff required specific training or had overdue supervisions and dates for completion were scheduled.

People and those important to them told us staff were knowledgeable and understood people’s needs. Comments included, “[Staff] are all well versed in what they have to do” and “I have no concerns at all about the staff or their knowledge.”

The provider’s recruitment processes were not always robust. We found applicants did not always have a full employment history documented and staff risk assessments had not always been completed where appropriate to ensure staff were employed safely and provided with ongoing support where necessary. Following our inspection, the provider confirmed they were reviewing their recruitment documentation to ensure all relevant information was in place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading. The provider had an infection prevention and control policy and training in place to support staff to follow good hygiene practices. During the inspection, we found minor concerns with cleanliness and the condition of fixtures in 1 communal bathroom. Following our feedback, the provider responded promptly to arrange replacement and review cleanliness checklists.

People’s medicines and treatments were safe and met their needs. People’s medicines were reviewed with relevant health professionals to ensure they were appropriate to people’s needs. However, the provider’s processes for documenting the administration of people’s medicines were not always implemented effectively. During the inspection we identified gaps in the recording of people’s refused and returned medicines and this meant it was difficult to confirm whether the amount of medicines in stock was accurate. This discrepancy in recording had not been identified by the provider’s own medicines auditing prior to our inspection. Following our feedback, the provider completed a full review of their medicines auditing processes and arranged for staff to complete refresher training.