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 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.

The provider had developed a philosophy of care that promoted a culture of honesty, understanding and responsibility. Daily and weekly managers meetings were held to discuss topics such as safeguarding, incidents, accidents and staffing levels. Various management meeting records showed discussions and actions in response to incidents that had occurred, with oversight to ensure actions had been completed and were effective.

Staff were given opportunities to identify risks and reflect and learn when things went wrong. Staff told us learning from incidents was discussed with them.

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 a planned and coordinated approach with the person, supported by their multi-disciplinary team (health and social care professionals working with the individual). This planned and collaborative approach ensured the person experienced a safe transition which 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 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 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.

The person told us they felt safe living at the home and with the staff.

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, “Will inform managers [of the abuse] and complete a Datix. The manager will advise us appropriately, I feel confident to report anything.”

The provider regularly reviewed accident and incident records to ensure any safeguarding concerns were appropriately identified, managed, and acted upon. The provider shared concerns where appropriate with the relevant agencies to enable them to take any required actions to keep the person safe.

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.

Staff were provided with guidance on how to support the person safely. Risks assessments and care plans were person centred and contained all the information staff needed to mitigate risks to the person safely. The person was involved in planning their care and how risks may affect them. Risk assessments were reviewed regularly and when needed, care plans were updated and changed. The person had a positive behaviour support plan (PBS) to support staff to understand their needs at times of emotional distress. It helped to identify triggers and strategies to use, to support the person safely and to care for their physical and mental health and wellbeing..

Staff provided care to meet the person’s needs that was safe, supportive and enabled the person to do the things that mattered to them. Staff we spoke with had a good understanding of the person’s needs and preferences.

The provider's systems and processes that assessed and monitored the environment and potential risks were 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.

We observed a calm and welcoming environment that supported the person’s safety, mental health and promoted their independence.

A Personal Emergency Evacuation Plan (PEEP) was in place for the person using the service. Emergency signage was visible and there was emergency lighting to alert those who were deaf that the fire alarm had been activated. The provider had appropriate plans in place to evacuate the person and staff in case of an emergency.

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.

The provider had robust recruitment practices in place including checking applicants provided a full working history, references and undertook a disclosure and barring check (DBS). DBS provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff told us they felt supported and safe to do their duty. Staff received regular supervision meetings to discuss their concerns, wellbeing and professional development. This ensured staff received ongoing support from the management team.

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 environment was clean and well-maintained.

There were systems in place to help prevent and control infections. Training records confirmed staff had received training on infection prevention and control. Staff were provided with personal protective equipment (PPE) when needed.

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.

The person self-medicated and relied upon staff to prompt and remind them and to take their prescribed medicines. Staff worked closely with the healthcare professionals and pharmacist to make sure medicines were managed appropriately.

The provider had a medicines policy and procedure that included supporting the person to safely administer their medicines. Staff completed medicine management training and were subject to regular competency checks to ensure they continued to manage medicines safely.

The person’s medication care plans contained detailed guidance of the support required of staff to ensure their medicines were managed safely.