Andrews Court 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 requires improvement. At this assessment the rating has changed to good.

The provider now followed robust recruitment processes to protect people from the risk of unsuitable staff. Staff now managed medicines safely and people received ‘when required’ medicines when they needed it. The provider now ensured suitable checks took place to ensure the safety of the premises.

Staff now assessed and mitigated risks. People now had thorough care plans to guide safe practice. They now had systems to protect people from abuse.

There were now sufficient staff to ensure people’s safety and meet their needs.

This service scored 66 (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.

When incidents or accidents had occurred, the registered manager was transparent with people. When concerns had been raised during this assessment, the registered manager had immediately acted to mitigate the risk.

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.

Prior to people moving into the service, a pre-admission assessment was carried out to ensure the service could meet people’s needs. The registered manager effectively shared information when people were admitted to hospital or required care at home after leaving the service.

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 safe and cared for. One person told us, “Oh yes, very safe; they look after me very well.” One relative said, “I would absolutely and categorically say [family member] is safe in here.”

The provider investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Staff had received safeguarding training and knew how to identify and report abuse. One staff member commented, “People are definitely safe living here.”

The provider worked with people to understand and manage risks by thinking holistically, although needed to improve some documentation related to core areas of risk assessment. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them[GB1][EH2].

Care plans and risk assessments did not always guide staff on how to manage risk and keep people safe. A variety of records associated with care and treatment were not always accurate, current, or recorded sufficiently. These included records for assessing and managing known behaviours and risks. One person was identified as having episodes of agitation. Documented strategies on how staff would support this person to remain safe were unclear. However, staff could tell us how they supported the person and manage the risk effectively. The management team reviewed the records and swiftly addressed these concerns.

Risk assessments related to the management of bed levers were not in place. The registered manager told us checks were completed daily by staff, but they did not have any systems of accountability or governance to ensure safety was maintained. There is a risk of entrapment with bed levers if poorly fitted. The registered manager updated their maintenance documentation to ensure formal checks were completed and recorded on a regular basis.

There were some risks noted to parts of the outside area should people be outside unsupported. The registered manager stated no-one would be outside alone but assured us they would review the current risks and take suitable actions if required to keep people safe.

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

Staff had good knowledge of fire safety procedures, and every person had a personal emergency evacuation plan (PEEP). The purpose of a PEEP is to ensure that all people can evacuate the building safely and promptly in the event of an emergency, regardless of their level of mobility or other health conditions.

Equipment was available and maintained to meet people’s needs. We saw evidence fire equipment, lifting equipment and electrical safety checks were completed as required by regulations such as Lifting Operations and Lifting Equipment Regulations 1998 (LOLER).

The provider made sure there were enough qualified, skilled and experienced staff, who worked together well to provide safe care that met people’s individual needs.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

There were appropriate staffing levels to make sure people received safe quality care and, when commissioned, 1 to 1 care.

Staff told us they were well supported by the management team and praised their compassion. Staff had regular supervision and appraisals, they said these were useful and enabled them to discuss training, their performance, and any concerns they had.

The provider did not always assess or manage the risk of infection, particularly in relation to risks associated with food storage.

Staff wore personal protective equipment when required and the environment and equipment was clean. The provider had a food hygiene rating of 5 which meant hygiene standards in the kitchen were very good. However, staff did not always follow required standards and practise when storing some foods. This was discussed with the registered manager who addressed and resolved the concerns.

People and relatives praised the cleanliness of the home. One person told us, “The home is nice and clean.” Another person commented, “The home is kept clean, it never smells.”

The provider made sure that medicines and treatments met people’s needs, capacities and preferences. However, some prescribed creams were not safely stored safely or disposed of when not required. The management team took action to ensure all remaining medicines were stored safely.

People received their medicines safely and as prescribed, administered by staff who knew them well. If people took medicines on an “when required” basis, written instruction to help staff identify when these should be administered was available for people.

Staff involved people in planning, including when changes happened and promoted people’s independence through the self-management and administration of medicines.

Appropriate arrangements for the ordering and disposing of medicines were in place and known by staff. A variety of regular medicines audits were carried out, and any shortfalls were identified with actions taken to minimise the risk of re-occurrence.