St Andrew's Healthcare - 17 The Avenue

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 newly registered service. This key question has been rated 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 breach of legal regulation in relation people’s safe care and treatment in the way people’s medicines were managed safely.

This service scored 50 (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 a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events.

Lessons were not always learnt to continually identify and embed good practice. Whilst the provider did have systems and processes that enabled learning from incidents, these were not fully effective in the actions taken to mitigate further risks from reoccurring.

Staff told us learning from incidents were discussed with them. Various management meeting records showed discussions and actions in response to incidents that had occurred, but there was a lack of oversight to ensure actions had been completed and were effective.

For example, records showed the local authority had raised a concern about the delay in reporting of an incident that impacted the person’s safety. Records also recorded how the local authority understood from information shared with them from the provider, that actions were going to be taken to reduce further risks. However, from speaking with the management team and reviewing care and staff training records, there was no evidence that the provider had completed actions they said they would complete. This shows a lack of openness and honesty with external agencies and a failure to take timely action to learn from incidents.

The provider worked with the person 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 the person moved between different services.

Care records showed and staff confirmed, how the person was supported to transition to the service from their previous placement. This was completed in a planned and coordinated approach with the person, and supported by the person’s multi-disciplinary team (health and social care professionals working with the individual). This planned and collaborative approach ensured the person experienced a safe transition and supported them to settle in their new environment, resulting in a positive outcome for the person.

Care records confirmed the person’s care journeys, and any associated risks were detailed to ensure staff could provide proactive, effective and continuous care and support. The management team confirmed their discharge planning systems and processes used to support people to transfer to alternative care settings and how information was shared with others. The provider also had systems and processes to share Important information with external healthcare professionals such as ambulance and hospital staff in the event the person was required to be admitted to hospital

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. We were concerned the provider’s systems and processes did not always concentrate on improving people’s lives or protecting their right to live in safety and avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

An incident record identified the person had experienced a medicines error in February 2025. Staff had failed to support the person to take their daily prescribed medicines. The provider’s incident record shows this error had not been investigated until 3 days after the event and had not been reported to the local authority at the time the incident occurred. Records also showed a lack of actions to mitigate further risks such as reviewing medicines management procedures. However, care records confirmed immediate actions had been taken to ensure the person’s safety and that the person had not come to harm.

The person who used the service told us how they felt safe living at the service and how staff supported them to remain safe.

Staff confirmed they had received safeguarding training and had access to the provider’s safeguarding policy and procedure. Staff understood their roles and responsibilities to keep people safe from abuse and avoidable harm. A staff member said, “Safeguarding is about taking care of the service users health and well-being. We have a duty of care, making sure the service user is safe and healthy, and reporting any concerns.”

The provider had a Deprivation of Liberty Safeguards (DoLS) policy and procedure to ensure any restrictions placed upon the person’s liberty was done so lawfully.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The person had a positive behaviour support plan (PBS) guidelines to support staff to understand their needs, identify triggers and strategies to use, to support the person safely at times of emotional distress. Also to support the person’s physical and mental health and wellbeing. We identified staff had access to 2 PBS plans, dated differently and guidance was also different. This put the person at risk of receiving inconsistent care and support. We raised this with the management team who took action and removed the outdated PBS plan.

The person’s care records including PBS plan, recorded details of specific health conditions and how these could impact the person’s mental and physical health, having a negative impact on them and others. However, there was no health care plan or risk assessment as to the actions required of staff to meet these needs safely and mitigate risks. We did note the PBS plan provided staff with some guidance of actions to take to mitigate this risk. However, an incident record dated November 2024 showed staff had not followed the PBS guidance and this had impacted the person’s and staff safety and wellbeing. The provider’s systems and processes had failed to sufficiently assess, plan and mitigate this risk, exposing the person and others to the risk of harm.

Fire risk management and procedures were not sufficiently robust. The person had a personal evacuation plan, but this record lacked details about how risks had been assessed and mitigated. For example, risk mitigation actions did not include information such as, whether the person did or did not have any additional equipment in their bedroom such as vibrating pad (for pillow/mattress) to alert them to a fire. It was not recorded whether the person would react to the flashing alarm alert and how the person may present in the event of a fire or event requiring them to evacuate the building.

Records confirmed fire evacuation tabletop exercises had been completed on two occasions during 2024. However, there were no details of what staff had attended and there was limited details of discussions and actions. There was no evidence of management oversight to ensure all reasonable actions had been taken to mitigate the risk of events requiring evacuation from the building. We were not sufficiently assured that fire risk and mitigation actions were robust.

The provider's systems and processes that assessed and monitored the environment and potential risks were not fully robust.

Health and safety audits and checks were completed on the environment and premises by staff at the service and by the provider’s estate teams. However, the internal checks completed by staff showed no oversight by the management team to ensure these were being completed correctly and any concerns identified were reported and actioned.

Where the provider’s estate team had completed health and safety checks, it was not clear who had responsibility to complete any identified actions. For example, an audit completed by the provider’s estate team dated October 2024 showed an overall score of 82%, this was across all the provider’s community houses visited. The compliance date for the shortfalls identified was 31 December 2024. However, the audit report did not detail actions, timescales and who was responsible. Following our inspection, the provider submitted additional information that confirmed the management team had access to the details of the audit findings and actions had been completed.

During the inspection, we did not identify environmental issues, but we were not sufficiently assured that the provider’s systems and processes were robust.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They worked together well to provide safe care that met the person's individual needs.

The staff rota showed, and the staff and management team confirmed, there were always sufficient staff available to support the person in accordance with their assessed care and support needs.

Whilst the staff rota was planned in advance and showed the person was supported by permanent staff who knew them well, it was also evident from speaking with staff and attending the staff daily handover, there was frequent use of bank staff (staff employed by the provider) who were deployed from the provider’s main hospital site when there was a shortage of permanent staff. These staff were not always trained in British Sign Language or were not familiar with the person’s care and support needs. This meant the person did not always receive consistent care and support.

The management team told us they were in the process of recruiting more permanent staff and plans were in place for staffing to be managed separately from the provider’s main hospital site. The management team told us how this would greatly improve people’s experience and provide consistency in care.

Whilst agency staff were used infrequently, we were concerned that agency profiles were not kept on site, but at the provider’s head office. This meant staff on duty were unable to effectively check agency staff ID details when arriving for work. The management team were addressing this.

Staff were recruited in a safe way. Appropriate checks were carried out before employment was offered so that as far as possible, only suitable staff with the right skills and experience were employed. However, we noted from a sample of staff files that gaps in their employment history did not record a reason and had not been followed up by the provider. We shared this with the management team.

Staff confirmed they received the training and support they required, and this included ‘supervision’ with their line managers so performance and any training or development needs could be discussed and planned. A staff member said, “We receive support from our managers and team leader. We have supervision and staff meetings, we do daily huddle meetings, which provides good interaction between staff and management.”

The provider’s systems and processes in infection prevention and control practice did not consistently follow best practice guidance.

For example, cleaning products were kept in accessible, unlocked storage and had no specific COSHH data sheets. This was unsafe practice.

Pedal bins were not used to reduce the risk of cross contamination. Cleanliness and hygiene in some parts of the service needed to be improved upon.

We asked to see cleaning schedules that confirmed cleaning tasks being completed. The management team were unable to provide this information and showed us a list of cleaning tasks recorded on the inside of a kitchen cupboard that staff were expected to complete. This information was minimal in detail and there was no recorded evidence cleaning tasks were being completed, and no evidence of management oversight. We were not assured there was robust infection prevention and control audits and checks being completed.

Staff had access to personal protective equipment and had received training in infection prevention and control and access to the provider’s policy.

The provider did not make sure that medicines and treatments were safe and met the person’s needs, capacities and preferences.

The person self-medicated and relied upon staff to prompt and remind them and to take their prescribed medicines.

Whilst the provider had a medicines policy and procedure that included the procedures required to support the person to safely administer their medicines, this had not been followed.

For example, the person did not have a specific medicines care plan that provided detailed guidance of the support required of staff in relation to ordering, collecting, storing of the person's medicines. Including, how the person took their medicines and actions required of any concerns. Neither had a self-administration risk assessment been completed and staff had not received medicines training and competency assessments. This meant we were not sufficiently assured prescribed medicines were managed safely and effectively.

We were aware a person had experienced a medicines error, whilst they had not experienced any harm, this was a potential risk which may have been avoided if medicine procedures were in place.