St Anns Healthcare - Main Office

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. This is the first assessment for this service. This key question has been rated 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 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.

Safety events such as accidents and incidents had been investigated and reported with actions taken to mitigate against recurrence. Actions taken included when other health professionals were called or local authority safeguarding informed. These records were reviewed monthly via an audit tool. From those records we noted some incidents that required notification to us had not been made. For example, where referrals were made to local authority safeguarding.

Where lessons had been learnt these were shared with the staff team to continually improve practice. The registered manager understood their responsibilities under the duty of candour which require providers to be open and honest following any 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.

Systems were in place to ensure continuity of care when people commenced with the service and there was involvement of the person, family members and external health or social care professionals. Preadmission assessments were completed to identify if people’s needs could be safely met by the service. Processes were in place to help ease transition to other services if needed such as emergency hospital admission information.

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.

People and their relatives told us they felt the service was safe. Incidents of safeguarding had been identified and shared with the local authority. People had consented to their care and treatment, and where relevant their legal representatives had been involved. However, where people were restricted with bedrails this had not always been considered in line with best practice and the Mental Capacity Act 2005 (MCA). This was addressed by the management team during the inspection. Staff had completed training in recognising abuse, MCA and in Deprivation of Liberties Safeguarding (DoLS).

The provider did not always work well with people to understand and manage risks. The provider’s systems and processes used for identifying and recording risk management was not always completed accurately or with current information. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk management and records were in place. However, some risks related to care and treatment were not always identified and where some risks had changed these had not always been reviewed in a timely way. The ones we noted as needing updating were addressed during the inspection. The provider had systems for the oversight of falls, trends and themes to consider how to minimise them. Staff told us they could access people’s records easily to follow risk management plans. Staff told us they felt they had received the right training to meet people’s needs safely.

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

Detailed individual risk assessments associated with the person’s home environment were completed before the service was commenced. The registered manager knew how to access specific equipment should this be required and staff had received training to use equipment safely. The provider also identified risks relating to staff commuting and lone working.

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. However, not all the checks of staff suitability to work with vulnerable people were available at the start of the assessment.

Staff who had been recruited from overseas or via the provider’s sponsorship scheme we found records of suitability checks were not readily available. We found not all documentation for staff recruited complied with the company policy procedures. A checklist to confirm suitability checks had been completed was in the recruitment files. However, no audits check on the files had been completed. Information about people’s suitability initially noted as missing was provided during the subsequent inspection site visit dates.

There were enough suitably qualified staff to support the number of people receiving services.

We noted from the training matrix that some learning still needed to be completed or refreshed. The provider planned. during the inspection, for any outstanding training to be completed. Staff told us they felt they had received sufficient training to care for people safely. People we spoke with thought staff were appropriately trained. One person said, “Staff are well trained and very effective in the way they work.” Staff told us they felt very supported by the management team to fulfill their roles.

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 in infection prevention and control and food hygiene to support good practice in this area. Personal Protective Equipment (PPE) was available and used where needed. The management team and care staff understood the actions they should take should there be a specific infection risk or concern for an individual person.

The provider did not always make sure that medicines record keeping supported medicines administration to safely meet people’s individual needs, increasing the potential for mistakes.

Staff had completed medicines training and had their competency regularly assessed. However, some administration of medicines was not always done in line with the prescription instructions. The registered manager took immediate action and consulted with the GP to amend the prescriptions for it to be in line with what staff were administering.

Records for some medicines that were given as and when required were available however, they did not always contain sufficient information relating to the reasons for administering and the dosages.

Medicines administration records for topical preparations such as creams were not always clear in their guidance and information on where creams should be applied. Issues identified during the inspection with medicines management records were addressed straight away.