St Anne'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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Regular management meetings were in place to review and analyse incidents and events. When required, staff reviewed and updated peoples’ care plans. This helped to prevent recurrence and drive improvement in the service.

Relatives told us they knew how to raise concerns with the service and felt their concerns would be addressed quickly. A relative told us, “I would feel comfortable reporting any concerns to the registered manager and yes, from what I've observed and how they interact with the staff, I do feel I would be listened to.”

Staff confirmed they knew how to raise concerns within the service. A staff member said, “There are multiple clear channels for raising concerns and sharing feedback.”

The service 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.

Relatives told us the service communicated with health and social care professionals when required. A relative said, “[Person] has had a few health issues and has had to go into hospital a couple of times, but [person] was always looked after as soon as [person] got back to the service.”

Staff contacted external health professionals as required. A staff member said, “I speak to health care professionals when taking the client to the doctor or hospital with their family.”

Health and social care professionals were complimentary about working with the service. One professional said, “My observations relate to the home’s flexibility and continuity of care, their understanding of individuals’ needs, and how effectively they have worked with me to maintain safe and consistent systems of care, particularly during periods where [person] has moved between services.” Another professional told us, “The service has worked with the individual to support them in a person-centred way, offering the staff they prefer to support them and linking in with [other health and social care professionals] and me.”

The service used an electronic care planning system. This meant people’s care plans and other relevant documentation was available in case of an emergency hospital admission.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

The provider had an effective process in place to ensure concerns were reported to the local authority quickly and appropriately.

Staff confirmed they knew how to report potential safeguarding concerns within the service and felt confident to do so. One staff member said, “The organisation has an effective communication channel that caters for any issue of concern. The feedback channel is also effective.” Another staff member told us, “We can raise concerns or give feedback through supervisions, team meetings, handovers, or directly to the registered manager. I feel able to speak openly if I have a concern about a resident’s safety or any issue within the home. Management has taken concerns seriously when raised.”

Relatives told us their loved ones were safe living at the service. One relative said, “I feel that [person] is very safe at the service because there is always someone there to watch [person].” Another relative told us, “Yes I do feel [person] is safe.”

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had been completed to assess people for risks to their health, safety and wellbeing.

We observed staff working with people and supporting them when they became distressed. This supported people to experience positive outcomes while remaining safe.

Staff knew people well and explained how to support them safely. A staff member said, “I do believe our clients are safe. The care staff follow safety procedures including regular observations, reporting health concerns, maintaining hygiene, using risk assessments and ensuring residents are treated with dignity and respect. Carers respond quickly if any resident shows signs of discomfort, illness or emotional distress, and the teamwork between staff ensures residents are supported consistently.”

The service detected potential risks in the care environment.

People’s bedrooms were personalised with posters and other items to make them feel homely. A relative said, “When [person] arrived at the service, [person] settled into the homely atmosphere immediately.”

The provider used external contractors to service the fire system and to undertake more specialised checks, including equipment checks.

People had personal emergency evacuation plans (PEEPs) which were readily available and up to date.PEEPs provide staff and emergency service personnel with critical information on the evacuation needs of each person in the event of an emergency.

The provider maintained the fire records for the service, however did not complete regular fire drills. These were commenced in response to our feedback and completed during the inspection. The registered manager introduced a plan to ensure the service completed regular fire drills for day and night.

We observed some of the carpets in the service were fraying and needed replacing. Some doorways required painting. The service had an environmental improvement plan in place to address these areas.

Staff told us they knew how to report concerns relating to the environment. A staff member said, “Environmental and maintenance issues are reported to the senior staff team and the maintenance department. Issues generally do get addressed, however sometimes require escalation to be completed.”

The service 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.

The service had safe recruitment procedures. They included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

Relatives were complimentary about staff. One relative told us, “The staff are well trained, and know [person] very well. Another relative said, “There seems to be a high level of staff.”

Staff received training appropriate and relevant to their role, however we found some training had expired. This was brought to the attention of the registered manager who organised for training to be completed and created a plan to ensure all training and competency assessments would be completed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff confirmed they had access to personal protective equipment (PPE). A staff member said, “We do have PPE available, including gloves, masks, aprons, face shields and hand sanitiser. When stock is low, we notify senior staff who then request replenishment through the internal ordering system. PPE is stored centrally and collected by staff as needed.”

The service had an up-to-date infection control policy in place.At the time of the inspection the service held a food hygiene rating of 5 which meant hygiene standards were very good and fully complied with the law.

We observed the service to be clean during both days of our inspection.

We received mixed feedback from relatives about cleanliness of the service. One relative told us, “Sometimes the home could be a bit cleaner, especially the bathrooms but it’s an old place; it isn’t always easy to keep it clean.” Another relative said, “I think the home is clean. [Person’s] room has been freshly painted. Flooring is clean, bedding and towels all nice and clean. Staff appear to remove used dishes quickly and surfaces appear nice and clean.”

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service did not always make ensure medicines and treatments were managed safely and met people’s need.

There were suitable arrangements for ordering and disposal of medicines.

If medicines were prescribed to be taken ‘when required’ there were person centred protocols in place to guide staff when these might be needed.

Records were in place to show that risks were considered for people using medicines such as anticoagulants, and flammable topical preparations. Where medicines were administered covertly, mental capacity assessments and best interest decisions were documented.

Staff had training and competency checks to support them with administering medicines safely. However, some competency checks were past the recommended one-year updates. Arrangements were put in place during our visit for these to be updated. Any errors or incidents were investigated and reported, so that systems could be put in place to prevent them recurring.

We found staff did not have a specialised training to administer 1 medicine to 1 person. We brought this to the attention of the registered manager who ensured a healthcare professional administered this medicine until the appropriate training was sourced. This was addressed during our inspection.