St Michaels Court

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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. Systems and processes were in place to review and investigate incidents, and measures were in place to mitigate risk from further occurring incidents. Staff were knowledgeable of concerns that should be raised and how to raise them appropriately.

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. Care plans and risk assessments were detailed meaning accurate information was available to staff in the event people had to move between services. This helped to ensure people received continuity in their care.

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 told us they felt safe living at the service. One person said, “I feel safe here because there are always people around to make sure I am alright.” The provider was proactive in reporting safeguarding concerns to the Local Authority and CQC. Staff knew how to report abuse and told us they had received safeguarding training.

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. However, feedback from relatives was mixed around their involvement in the review of care plans. One relative said, “I don’t have a copy of a care plan, and we haven’t had a review even though I think (relative) needs have changed”. One person said “We did have a discussion just after I came here but not since. If I need anything doing, we just talk as we go along”.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. During our assessment inspectors did not observe any concerns with the environment. The environment was clean and homely. The provider had effective processes in place to monitor that the environment was maintained and safe.

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. Staff files showed that staff were recruited safely. Based on the dependency tool, there was sufficient staffing at the service, however we discussed the feedback from staff during our site visit and the pressure sometimes felt by staff, especially on the first floor to meet people’s needs based on the staffing numbers. In the last 6 months, the service had an increase in admissions, therefore this has impacted the first floor which is predominately for people living with dementia. Since this was discussed, the provider and registered manager have made the decision to implement an additional staff member daily to support the service.

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 had access to personal protective equipment (PPE). We observed a clean environment and staff using PPE during our site visit. One relative said, “The first thing I am aware of when I go in is that it smells clean, no sticky floors, and the cleaners are visible.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Records we checked showed that people received their medicines as prescribed and we noted medicines were being stored safely. We found that records for the administration of medicines needed on an ‘as required’ basis did not always give staff full information, however this was discussed with the registered manager during the site visit and resolved. Staff were regularly assessed as competent to give people their medicines.