St James 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.

This is the first assessment for this service since a change of provider in October 2025. 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 a legal regulation in relation to people’s safe care and treatment, in respect of how risks were managed and the how people’s medicines were managed.
 

This service scored 59 (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. Staff listened to concerns about safety and investigated and reported safety events. However, individual people’s care plans were not always updated to reflect changes in their needs or highlight risks posed to them. Opportunities for sharing learning when things went wrong were taken. Lessons learnt were shared across the organisation.

Staff told us they knew how to report incidents and accidents. However, we found there was a lack of action after accidents to ensure records were updated.

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.

People who had been admitted to hospital were supported to return home. Staff maintained good communication with external bodies when people were away from their home.

People were supported by a small number of staff, this helped to ensure continuity. The manager told us this had been a recent change following feedback from relatives. A relative told us, “The care provider is aiming to have approximately 4 members of staff that will be providing care to our [relative], for confidence and consistency, which we will continue to monitor.”
 

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.

Systems were in place to identify, report and manage safeguarding concerns. The manager had worked with the local authority to investigate recent neglect concerns.

Staff had received training and told us they were aware of their responsibilities. Comments from staff included, “I understand my responsibility to recognise and report any safeguarding concerns immediately by following the service’s safeguarding policy and informing the appropriate senior staff or manager” and “I would look for signs such as unexplained injuries, neglect, changes in behaviour, poor hygiene, financial abuse or anything that doesn't seem right. If I had concerns, I would report them immediately.”

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 which was safe, supportive and enabled people to do the things that mattered to them.

People were placed at higher risk of harm due to shortfalls in risk management. For example, people who had fallen and who were at continued risk of falling did not have a risk assessment in place to guide staff on how to prevent a reoccurrence. People who were supported with bathing and showering did not have any guidance for staff on how to do this safely. We noted one person had adaptions in their bathroom and no risk assessments were in place for staff to follow.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People were not always supported by staff who had access to reliable equipment in the event of a fire. Communication aids [walkie talkies] available for staff to use in the event of a fire were not working and had not been charged. A member of staff told us they did not use them. The manager told us they had not received any fire marshal training to date. They had been in post over 6 months.

However, other environmental risks had been assessed and mitigated. Where people chose to smoke, risk assessments were in place.

The extra care facility was undergoing major refurbishment work. A risk assessment was in place to ensure all hazards had been considered.

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.

People were supported by enough staff. People told us staff were familiar to them. People were supported by staff who had been checked to see if they were suitable to work with them. All new staff were subject to a Disclosure and Barring Service (DBS) checks which provided information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Systems were in place to ensure staff had training and were checked to ensure they were competent. Staff had 1-1 meetings with a line manager to discuss their professional development. Staff gave us mixed feedback about how supported they felt. One member of staff told us they received feedback from their manager through “supervision meetings (with a manager), observations and day-to-day communication”. However, another member of staff told us, “Regular feedback would help staff feel more valued”.

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 received training in the prevention of infections. Staff had access to personal protective equipment when needed. One relative told us, “The staff that we have observed wear gloves.”
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were placed at greater risk of harm due to the lack of effective risk management for high-risk medicines.

People who were prescribed medicines which had the potential to cause internal and external bleeding did not have risk assessments in place to advise staff on how they should monitor the person for any bleeding.

People who used emollients or other flammable medicines did not have care plans and risk assessments in place to alert staff on how to prevent harm due to fire or burning. One person who received support from staff with the administration of flammable creams was a smoker. This alongside the person’s history of fire safety incidents increased the risk of fire. The lack of risk management plans meant they were at increased risk of fire and injury.

People were prescribed medicines for as needed use (PRN medicines). We found PRN protocols were in place, however, these were either not accurate or did not provide enough guidance for staff on how to safely support people. For example, one person’s paracetamol PRN protocol was not clear on how frequently they should have it.

People were supplied with a lockable medicines cabinet. The provider’s policy stated staff should discuss with people about how medicines should be stored. No discussion had been had with people to ensure who and how medicines should be checked to ensure they were stored within the manufacturers' guidelines. No checks were carried out to ensure the temperature of medicines did not exceed a safe threshold. This had the potential to make the medicines less effective.

One person’s family provided creams for them, staff told us they supported the person to administer them. However, the support for the cream was not detailed in the person's care plan. This was not in line with best practice guidance and the provider’s own policy.

The shortfalls in the management of medicines placed people at greater risk of potential harm.