OSJCT Athelstan House

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Incidents and accidents had been managed effectively. Staff completed incident forms recording all facts around what had taken place. These had been reviewed by the management team to identify any learning or changes needed to safe ways of working. If needed, referrals had been made to the local authority team and notifications submitted to CQC.

The registered manager showed us a recent incident where concerns were identified around people’s safety. This had been due to a lock failure on an external gate. There had been a full investigation and an analysis of causes. The registered manager told us they had escalated this incident for an internal review as they felt the provider’s policy needed to change with regards to checks during the daytime. The provider was supportive of any member of staff submitting suggestions to improve safety.

Learning alerts were shared will all the provider services when any incidents or near misses had occurred. The registered manager shared these with staff and had asked them to sign the alert to confirm understanding. Learning was also discussed in handovers, team meetings and staff supervisions.

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.

People’s health conditions were documented, and people were supported to access services from a range of professionals. The provider ensured information was shared with external healthcare professionals. Assessments completed when people started using the service ensured there was detailed information about any additional services they were accessing. This ensured support was maintained, including any contact with specialist nurses.

The registered manager showed us systems which made sure people’s health records went with them in the event of an admission to hospital. Staff could easily access a portable care plan which gave emergency medical professionals a range of information about people’s health needs. If people had short stays in hospital, management re-assessed people’s needs before a return to the service. This made sure if people needed additional equipment, it was in place for them on discharge. Hospital staff shared discharge planning records with staff which recorded any changes to needs or medicines. This information was checked against people’s current records and shared with the person’s GP.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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.

At our last inspection we made a recommendation for the provider to review their training to assure themselves staff understood safeguarding systems and processes. At this inspection we found this had improved. For example, the registered manager showed us they had placed information about safeguarding on notice boards in different languages. Some staff were from overseas and appreciated the information being available in their first language. Staff had also had additional training to check their understanding of processes. Staff were able to discuss their safeguarding responsibilities clearly, identifying how to challenge poor practice and how to report concerns.

Management teams had identified people who lacked capacity to agree to the care and support provided. They had followed the correct procedures to ensure they were supporting people in the least restrictive way. Management demonstrated they had approved Deprivation of Liberty Safeguards [DoLS] authorisations in place for most people that required it and applications for DoLS for the rest of the people who needed them. The service was complying with any DoLS conditions.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health, safety and welfare had been assessed and plans developed to manage those risks. Plans were regularly reviewed and updated, for example when people’s needs changed or in response to learning from incidents. Where people experienced any distress, there was clear guidance for staff about how to provide safe support. The provider’s specialist dementia nurse was involved in writing risk management plans for any support needed with distressed reactions.

We saw that people had been involved in completing and reviewing risk assessments related to things they wanted to do. For example, the provider had taken actions to mitigate the risk to a person whilst having regard for their capacity and right to make an unwise decision.

Staff were not using restraint at this service. People and relatives did not share any concerns with us about this quality statement.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider identified and responded to environmental risks in a timely manner. The environment was generally clean and well maintained, although some areas required maintenance. For example, some areas had walls that needed painting to cover scuff marks. Maintenance of the environment was an action on the service improvement plan.

The provider had a range of policies, risk assessments and guidance available to support staff and people to remain safe within the environment. These included documents for fire safety and adverse events such as power failure. The provider had systems to ensure equipment was serviced and maintained in line with national guidance.

The provider completed regular fire audits and tests on fire equipment. However, some of these tests were not completed within the timeframes identified in the provider’s policy. For example, weekly tests on the fire alarm system were not always completed within seven days. The registered manager told us they were aware of the gaps in recording and were taking steps to make testing more consistent. The registered manager told us any faults in the fire system would be visible in the fire control panel enabling staff to take immediate remedial actions.

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 safe care that met people’s individual needs.

Staff had been recruited safely following the required pre-employment checks. When staff started work, they received an induction and the required training for their role. The provider had a learning and development worker who visited the home and provided more bespoke training as needed. This worker helped monitor training completed so staff could be prompted to complete any refresher courses.

During our site visits we observed there were enough staff available to safely meet people’s needs. The registered manager said the retention of staff at the service had greatly improved. This meant the service was not using agency staff to fill staffing rotas. People and relatives said there were enough staff available most of the time. Comments included, “We do seem to see the same staff a lot of the time, so staff retention is probably better than some homes” and “Staffing is just about ok at the moment, but if they get more residents then there are not enough staff.” The registered manager told us they used a dependency tool to calculate staffing numbers which was reviewed regularly to include any increase in numbers of people. The provider also completed observations of busy times such as mealtimes which included a review of staffing numbers.

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.

The service was clean and feedback from people and relatives confirmed they found cleanliness to be of a good standard. One relative said, “I would like to highlight that the home is always scrupulously clean.”

All necessary personal protective equipment (PPE), including gloves, aprons, and masks, were available in full supply. Staff were seen to be wearing PPE appropriately. Staff completed regular infection prevention and control audits which included observations of staff handwashing techniques for competence. All staff completed training on infection prevention and control.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People had regular medicines reviews completed by a local pharmacist. This helped make sure people were on the right medicines for their health conditions. People and relatives said staff helped them manage their medicines well. Comments included, “I have medications with my breakfast, at lunch and with my tea. It all seems to go pretty well. If I am out, then they [staff] seem to catch up when I am back” and “Medications have been expertly managed and administered.”

Staff received training in the safe management of medicines and a manager regularly observed their practice to ensure they were doing this safely. Staff kept accurate records of the medicines people had been supported to take and the number of medicines held in the service.

Medicines audits were completed regularly identifying any areas for improvement. Any medicines errors had been thoroughly investigated and action taken to learn from the mistake. This included reviewing processes with the pharmacy.