St Annes Residential 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. 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 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.

Accidents and incidents were robustly documented and staff spoke of confidence in knowing what to report when. The registered manager undertook regular reviews of these to identify any themes or areas of improvement. These were then communicated to staff to aid learning and prevent reoccurrence. Staff told us how they received emotional support from the management following certain incidents and are supported with their reflections on how to drive improvements going forward. Policies were in place to help guide practice with regard to learning from events.

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.

The management team carried out a full assessment of people’s care needs before they came to live at the home. People and their relatives were involved in these assessments to help ensure they reflected the needs and wants of the person. When people had to attend external services, such as a hospital, their care plan could be fully downloaded from the electronic system and shared with the relevant agencies. This supported their care needs to continue to be met in other environments.

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 were happy at St Annes. One person told us, "I feel safe in here. [Staff] look after me well, they really do”. A relative said, “I don’t have to worry, [Person] is definitely safe.” Staff had completed training in safeguarding and demonstrated a good knowledge of how to identify and report abuse. One staff member said, “I would tell the seniors or managers if I was worried about anyone. I know that they would take action to keep people safe.”

The registered manager had a system to record any safeguarding incidents when necessary. They would undertake investigations as appropriate and work alongside the local authority safeguarding team to protect people from harm. Matters had been reported to the CQC where required. Where people were restricted, Deprivation of Liberty Safeguards (DoLS) had been applied for.

The provider worked with people to understand and manage risks by thinking holistically. However, some of the documentation around managing these risks required improvement. For example, when it had been identified that a person required support to reposition themselves to minimise the risk of pressure sores, the repositioning had been completed by staff but the detail in documenting this was not consistent. The registered manager was receptive to this feedback and implemented a clear turning chart for staff to complete whilst inspectors were on site.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks had been assessed and were documented in people’s care plans, along with guidance on how to minimise these. People were supported to take positive risks, where appropriate, to promote choice, control and independence.

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

The registered manager completed regular checks across the service to ensure that it remained safe for people. Environmental checks, such as fire and gas safety, were in place and effective. People had personal emergency evacuation plans (PEEPs) which were readily available and up to date. The environment was clean and tidy, and equipment was stored safely. Regular upkeep checks of moving and handling equipment had been completed.

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.

We observed enough staff during our inspection to support people safely. Staff told us they had enough time to carry out their duties, there was a calm atmosphere, and people were not rushed. Staff received regular training and 1:1 supervision to support them in their role. New staff undertook a robust induction, they told us, "We had a 6 week-long induction, this involved shadowing all different roles, night and day shifts. We covered getting to know people, how processes run, what the expectation are, care standards and how to access policies and procedures. We were assessed after 6 weeks to see if we were competent. It was thorough.”

The provider had a robust recruitment policy, and pre-employment checks were completed on all prospective staff. These included proof of right to work in the UK, previous employment references and criminal records checks.

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.

Processes were in place to minimise the risk and spread of infection. Staff were observed to appropriately wear personal protective equipment (PPE) when providing support with personal care. Staff had also undertaken training about infection control. Cleaning schedules were in place to help ensure the home was appropriately cleaned and the registered manager had good oversight of these. Any issues identified had been addressed quickly. The premises was visibly clean during our inspection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences, however, some of the documenting of medicines needed to be more robust. For example, where people had ‘as and when’ medicine (PRN) administered, this was marked correctly on their medicine administration record (MAR) but had not consistently been added to the additional PRN protocol sheet, meaning the reason for giving and effectiveness was not always possible to determine. The registered manager was receptive to this feedback and addressed this with staff immediately. They also identified that one person was having PRN medication regularly and as such they requested a GP visit to review this.

Staff involved people in planning, including when changes happened. Some people were encouraged to manage their own medicines as they were able to do so. We observed people being supported to take their medicine in line with their preferences. Medicines were stored securely, and audits were completed to ensure stocks were correct and MAR charts were accurate. Staff had received the appropriate training and regular competency checks were completed by the management team to ensure they remained suitable to safely handle medicines.