Ann 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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

Staff knew how to report safety incidents which were investigated by the management team and immediate actions were taken where required. One staff member told us, “We report incidents on our (incident reporting) system and in care notes. We record exactly what has happened, and techniques used in physical intervention, if that was required.”

The service used a sophisticated system to analyse data from safety events and carried out regular audits of incidents. The service ensured training was adapted to ensure new learning from data analysis was shared with staff; and people’s support was updated where required. One member of the management team told us, “Our data showed there were spikes around mealtimes which led to changes in the support we provided.”

Learning from incidents was shared in staff meetings and one-to-one meetings with staff.

The service 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 a multidisciplinary team including occupational therapy, psychology and positive behaviour support. The service had good links with external health and social care professionals and ensured up to date information was shared where appropriate.

People had digital health passports which could be shared with health partners such as hospitals to ensure continuity of care. Their passports included personalised information such as their communication and behaviour support needs.

Staff were proactive in supporting people with transition. The registered manager told us, “We ensure people's needs are compatible with people already living here.” Another member of the management team told us, “We do a lot of transition work as people can find transition hard, including changes between day and night staff.”

The service worked with people and healthcare partners to understand what being safe meant to them; and concerns were shared and investigated where appropriate. However, internal safeguarding processes were not always effective.

One person’s risk assessment was not updated effectively following behavioural incidents in community settings.

The service’s safeguarding policy was not service specific and did not include locality contact details.

Safeguarding information and how to report safeguarding issues was not always readily available to people or those visiting the home.

When the inspection team informed the management team about these concerns, they addressed them straight away.

Where people needed to be deprived of their liberty to keep them safe, the service ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority. A log was in place to ensure staff could check the status of these applications. The service had been very proactive in responding to a recent change in legislation in this area and were actively working toward reducing people’s restrictions, where appropriate.

The service 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.

One relative told us, “I can tell by the way staff approach [person] that they are very good, and they are in a safe place.”

Staff had received positive behaviour support (PBS) training and felt confident in using positive behaviour strategies. One staff member told us, “Our PBS lead is very knowledgeable, and I have learnt a lot from them.”

The service worked proactively with people and other stakeholders, including advocates, to ensure people’s behavioural risks were managed effectively, using least restrictive practice. One staff member told us, “We try not to wrap people in cotton wool, and we promote positive risk taking. We review people’s risks regularly and staff have had positive behaviour support training.”

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

One relative told us, “The home is a well-maintained and it’s a safe environment.”

There were effective systems to ensure the environment was kept safe. Environmental risk assessments were in place such as fire safety, gas safety and water safety. These were up-to-date and where issues were identified, these had been addressed or there was a plan in place to address them. Regular audits took place to monitor the safety of the premises and equipment.

Routine testing took place for fire alarms and evacuation procedures. One staff member told us, “We have fire safety training, and have frequent drills to ensure staff and residents know what to do in the event of a fire.”

There were coded doors to help restrict access to non-communal areas to keep people safe. People had Personal Emergency Evacuation Plans (PEEPS) in place to guide staff how to evacuate people safely in the event of an emergency.

However, we observed several areas where the décor was damaged or stained including in people’s rooms. The management team recognized that environmental improvements were required to ensure the premises were well-maintained and promoted people's dignity. Following our inspection, the registered manager confirmed refurbishments to the premises had been approved by the provider.

The service 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.

The service ensured there were enough staff to ensure people were supported on a one to one or two to one basis to access the community and appointments. People also had access to core staff support.

Team meetings, one-to-one meetings and daily handovers were in place, to support staff to provide safe care to people.

Staff had received the required induction and training to undertake their roles safely. One staff member told us, “My training is refreshed annually. We have face to face training including safeguarding, Oliver McGowan and positive behaviour support.”

Staff were recruited safely and appropriate background checks were completed, including for staff who were recruited via a sponsorship scheme.

The service worked proactively to prevent a closed culture. A member of the management team told us, “We ensure staff work different patterns and with different staff members to address the potential of closed cultures.”

Processes to manage the risk of infection were not always effective.

While the premises appeared clean and hygienic, and records demonstrated regular cleaning took place, damage to the physical environment, décor, and fittings meant there was a risk these surfaces could not be cleaned effectively.

We observed some refrigerated foods had not been labelled with opened and expiry dates and temperature records for the drinks station contained omissions.

When the inspection team informed the management team about these concerns, they addressed them straight away.

We observed staff wearing personal protective equipment [PPE] where required. Staff told us there was always enough PPE available.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People were supported to take their medicines when required. However, improvements were needed to ensure people’s care plans included clearer information about what they could manage independently and where they needed staff support.

Information was not always available about where people’s creams should be applied, and body maps were not always completed.

Reasons for giving ‘as required’ medications were not always recorded effectively, and staff did not always record how effective the medication was, following administration.

When the inspection team informed the management team about these concerns, they addressed them straight away.

There was an up-to-date medicines policy in place.