St John's 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 good. At this assessment the rating has changed to 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 to people’s safe care and treatment, the ways people’s medicines were managed, staff and leaders’ skills and development and the environment.

This service scored 53 (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 promote a positive learning culture and there were missed opportunities to improve people's safety through shared learning from incidents. Systems were in place to review incidents and accidents but learning was not always embedded into practice. Staff could not consistently explain lessons learned from incidents or describe how changes had reduced risks for people. During the inspection, some staff spoke about reflecting on incidents, but others, including senior support staff and the registered manager, were unclear about what learning had taken place and how it had been shared.

Safeguarding measures to prevent incidents were not consistently identified and action to prevent them happening had not always been taken. This limited the provider's ability to identify trends and make improvements. Despite these findings, some relatives felt the service responded positively when concerns were raised.

The provider generally worked well with people and partner agencies to support safe systems of care and ensure people experienced continuity when moving between services.

People's transitions into the service and between healthcare services were planned and coordinated. Systems were in place to manage referrals and support people to access healthcare professionals when needed. People and relatives told us care was smooth when moving into the home and they were kept informed about important changes. One person said, "Everyone is lovely, I’ve settled in well." A relative told us, [Staff and managers] always communicate with me.”

However, records did not always contain enough detail to consistently support safe care. Care plans were not always sufficiently personalised or regularly updated to clearly guide staff on how to meet people's needs. This meant safe care relied heavily on staff knowing people well and sharing information through day-to-day practice rather than through clear written guidance.

The provider did not always have effective safeguarding systems in place to protect people from abuse, neglect and avoidable harm. Concerns were not always shared with relevant agencies in a timely way and safeguarding records did not always demonstrate appropriate oversight.

Staff understood their responsibility to report concerns and could describe different types of abuse. However, not all staff could explain how abuse may present in practice. This increased the risk that signs of abuse, neglect or poor care may not always be recognised promptly.

Mental Capacity Act 2005 processes were not always robust. Mental capacity assessments had been completed and applications for Deprivation of Liberty Safeguards (DoLS) had been made where restrictions were required. However, records contained contradictory information about some people's mental capacity status and did not consistently show how decisions had been reached, what alternatives had been considered or why restrictions were necessary. We requested documentation relating to the authorisation of DoLS for one person, but this was not made available during the inspection. Without this form, the registered manager and staff could not verify whether restrictions were lawfully authorised or whether any conditions attached to the authorisation were being met.

We also identified a blanket restriction on visitors during mealtimes. This was not reflected in care plans or DoLS documentation to demonstrate the individual risk and rationale for the restriction. Staff gave differing accounts about how and why it was applied. This created a risk that restrictions may not always be understood or implemented consistently in the least restrictive way.

Despite these findings, people told us they felt safe and relatives generally spoke positively about people's safety and the support provided by staff. One relative told us, "Yes, I do feel they are safe. It is the security that makes it. The staff are all lovely too."

The provider did not always involve people and their relatives effectively in managing risks. Risks to people's health, safety and wellbeing were not always fully assessed, recorded or reviewed, which increased the risk of inconsistent care.

People and relatives told us they felt safely supported by staff. However, inspection findings showed important risks had not always been identified or documented. Risk assessments were absent, incomplete or lacked detail for a range of known health conditions including seizures, choking, falls and medicines. This meant staff did not always have clear guidance about how to manage risks associated with people's individual needs. Not all staff were able to demonstrate an understanding of the risks and some were not aware the person had the diagnosed condition.

Opportunities to explore alternative approaches to care had not always been considered. For example, one person experienced recurrent urinary tract infections and distress related to management of their catheter, but alternatives to their existing catheter management had not been fully explored. People’s preferences in relation to having their bedroom doors open, shut or locked and any associated risks of that choice, were also not always assessed.

Despite these findings, people and relatives were positive about the support provided by staff. One relative told us, "Yes, I think they manage risks. Certainly, [my family member] has not said anything to the contrary."

The provider did not always ensure the environment, equipment and facilities were maintained in a way that fully supported safe care. The environment was generally safe and people were able to access communal areas and receive care in a clean setting. However, parts of the home required ongoing maintenance and redecoration. During the inspection we observed damaged woodwork and marked walls in several areas. The provider had not always identified and addressed these issues promptly.

The provider had not fully considered how the environment could better support people living with dementia. Some areas lacked features that would help people orientate themselves and move around the home as independently as possible. Improvements were needed to ensure the environment reduced confusion, promoted independence and supported people's safety and wellbeing.

The provider did not always ensure there were enough skilled and knowledgeable staff to consistently meet people's needs safely. Systems to support staff development and monitor competency were not always effective.

Recruitment processes included appropriate pre-employment checks to assess staff suitability.

However, during the inspection some staff, including the registered manager, had difficulty understanding questions even when these were rephrased and explained. This raised concerns about staff communication skills and their ability to support people with communication needs effectively. Relatives mentioned this as a theme in their feedback regarding staff being difficult to understand and/or speaking in languages people did not know. One relative said, “They are all very kind. I would add though that there are a lot of carers who speak openly in their mother tongue, which people will be hearing and confuses them more."

Staff knowledge of people's needs was not always consistent. Some staff, including the registered manager, demonstrated limited understanding of people's diagnosed health conditions and how these should be supported. Although dementia champions had been identified, staff knowledge of different types of dementia was variable and some staff were unaware of key diagnoses affecting people they supported. This increased the risk of people receiving inconsistent care.

Training was provided for staff but systems to support staff understanding and development were not always robust. Supervision and appraisal records contained limited evidence of staff involvement, development planning or measurable objectives. There were also insufficient evidence of competency checks and follow up action to assure staff remained knowledgeable and competent in their roles.

The provider did not always effectively assess and manage the risk of infection. Some areas of the home did not support good infection prevention and control practices. Two bathrooms had a strong urine odour; stained flooring and sections of sealant had significantly deteriorated. These areas had not been maintained to a standard that supported effective cleaning and preventing infection. Poor maintenance of fixtures and fittings can make effective cleaning more difficult and increase the risk of infection spreading.

Staff had received training in infection prevention and control and told us they had plenty of access to personal protective equipment such as disposable gloves and aprons. Hand sanitiser was also available throughout the home and cleaning schedules in place. Relatives were generally positive about the environment and caring nature of the housekeeping staff. One relative told us, "Absolutely, it is clean, yes. The [housekeeping] staff are just not [housekeeping] staff, they are just as considerate and caring as the [care staff]."

The provider did not always make sure that medicines and treatments were safe and met people’s needs and preferences. Creams and emollients were not stored securely placing people at risk of accidental harm.

Information about known medicine sensitivities and allergies was not shown consistently across all records. It was unclear if the supplying pharmacy had this information provided to them as an additional check when supplying medicines.

Some people were prescribed medicines to be taken as needed (PRN). Guidance available to staff lacked sufficient detail, including how long medicines could be used consecutively before contacting the prescriber. Where people were prescribed more than one PRN medicine for the same purpose, guidance was not always clearly explaining which medicine should be used and when. This could lead to medicines being administered inconsistently or inappropriately.

There were records about the application of peoples prescribed medicated skin patches to sites on their bodies. However, the records did not always show that the sites of application had been properly varied to reduce the risk of skin reactions from the patches.

Staff had received medication training and had their competence regularly assessed to ensure they continued to manage people’s medicines. They followed safe procedures when giving people their medicines but did not always involve people in planning.

There was some person-centred information available for staff to refer to. This included personal identification and guidance about how people preferred to have their medicines given to them. However, guidance for people who had their medicines prepared by crushing them in food or drink, did not reflect this or give detail about how each medicine was to be prepared and administered. In addition, there was a lack of records showing that advice on this had been received from an appropriate healthcare professional.

Managers carried out regular checks of medicines and their records. There were systems in place for staff to raise medicine errors and incidents. However, audits had failed to identify the concerns we found.