Anna S Proctor House Care 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 requires improvement. At this assessment the rating has remained 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 service was in continued breach of legal regulation in relation to medicines management.

This service scored 59 (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 an effective culture of safety based on learning lessons and establishing good practice. At our previous two assessments of the service the provider was found to be in breach of regulation due to unsafe medicines management. Action plans were completed after those visits setting out how medicines management would be improved. At this latest assessment medicines management was still unsafe meaning lessons had not been learned and good practice was not embedded.

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 and those close to them spoke positively about their experience of moving into the service and said they had felt supported when doing this.

People were safeguarded from abuse. The provider shared concerns quickly and appropriately. Staff received safeguarding training and said they would not hesitate to report any concerns they had. One member of staff told us, “If I saw something concerning I would ensure it was documented and I would speak to the management team, including deputy managers and the senior team lead, about my concerns.” People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). Staff were working within the principles of the MCA and managed DoLS appropriately.

Most risks at the service were effectively assessed and monitored. This included risks relating to people’s health and wellbeing as well as the safety of the premises and equipment. People were supported with positive risk taking, for example in relation to using the kitchen and accessing community services. However, the provider did not have effective systems in place to manage medicines and this placed people at risk. Following our visit the registered manager sent an action plan to say how these issues would be addressed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Required testing and servicing certificates were in place. Plans were in place to support people in emergency situations that disrupted the service. People had been involved in a recent redevelopment and redecoration of the service, which had include including them in decisions on the layout and look of the premises. People and relatives told us the building met people’s support needs and preferences.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. We saw that people received support quickly when this was needed, and people and relatives did not raise any concerns about staffing levels. Staff spoke positively about the support they received with training, supervision and appraisal. One member of staff said, “I have undergone regular supervisions in a range of aspects including housekeeping, infection control and moving and handling, which are always focused and informative as they allow me to learn from others and develop my practice.”

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. Staff received training infection prevention and control, and the premises were clean and tidy when we visited.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Records did not always evidence that an effective system was in place to ensure medicines were safely managed and administered.

Medicine records were not always clear. For example, where non-administration codes were used, they were not always clearly defined. A running balance was in place for assurance but where staff had identified that stock did not balance with records this was not escalated for investigation. Some medicines were out of stock and could not be given. This meant we could not be sure medicines were administered as prescribed.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Since our last inspection guidance for how these medicines should be administered was now available however, they were not always person-centred and some were still missing.

Records were not in place for all creams applied by care staff as part of personal care. Patch application records were not available to demonstrate rotation in line with manufacturers guidance to prevent side effects.

Medicines were stored securely and safely. Comprehensive policies and procedures were in place to support the administration of medicines. Management completed audits of medicines, but these had not identified all the issues we found at inspection. Following our inspection the registered manager sent an action plan to say how the issues would be addressed.