Anahita Recovery Centre

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 inspection we rated this key question Good. At this inspection the rating has remained 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 effective systems for reporting and learning from incidents. The registered manger shared learning from incidents, accidents, complaints and safeguarding concerns with staff at team meetings. We saw reflective practice meetings were held with staff to improve their practice. A staff member told us, “Reflective practice sessions are good, there’s usually one topic per session. All the staff can join in person or online, we discuss areas around the topic and reflect and learn.”

Staff worked effectively with health and social care professionals to ensure people received appropriate support when meeting their physical and mental health needs. These professionals included GP’s, hospital staff and community mental health teams amongst others. A health care professional told us they visited several people with complex care needs living at the service. They said the service managed people very well. Staff were responsive and maintained regular contact with their team. The service provided updates regarding people’s presentations, compliance with medication, and risk incidents. Staff regularly accompanied people to medical reviews and always provided comprehensive written care program approach (CPA) reports which were very helpful.

There were reporting systems in place, and management demonstrated a proactive approach to safeguarding. There was good oversight of safeguarding concerns and accidents and incidents. Staff told us they had received training on safeguarding adults from abuse, and they felt confident any concerns they raised would be managed appropriately. Records showed that appropriate actions were taken by staff where required following any concerns and adverse events.

Risks to people were being managed however, on the first day of our inspection, we found that people’s care records were not always stored together. The providers electronic care planning system held care plans and risk assessments however referral and initial assessment information had not always been saved onto the system. Managers spent time looking for some of the records we requested throughout the day. The registered manager told us the service had been in the process of transferring people’s care records from one system onto a new system. The new system was not what they expected and had left some shortfalls.

On the second day of our inspection the registered manager produced copies of people’s care records for us to review. These had been generated from the previous system. This included referral information, the providers initial assessments, care plans and risk assessments. Care plans referred to people’s mental health needs, recovery goals and intervention plans for support. Interventions were related to the recovery goals and reflected the person’s preferences, views and feelings about their health and wellbeing. Risk assessments acknowledged the person’s history of risk and had clear monitoring and ongoing support and encouragement to promote supportive working relationships.

Staff told us they had access to care records, they were easy to understand, and they were notified when people’s care plans and risk assessments were updated. Following our inspection the registered manger told us they were reverting to the previous care planning system because it stored and generated documents that were clearer and easier to understand. The platform also gave them more latitude to adjust care plans and risk assessments according to people’s individual needs.

The design of the premises met people's needs. People had en-suite bedrooms, which had been decorated and furnished to their choice. People told us the service was clean, some people told us they received support from staff with cleaning their rooms. There were quiet rooms for people to relax in or to receive visitors in private. People had access to a pool table, board games, tea and coffee making facilities in the lounge. In the garden there was suitable furniture for people to relax in, a greenhouse with tomatoes, raised beds with beetroot and cabbages and people could also tend to an allotment nearby.

We saw regular servicing was carried out on the fire alarm system, portable appliances, gas safety and water testing. We saw a report from a 2 monthly health and safety checklist. This covered areas for example, security, access for emergency vehicles, fire alarms, window restrictors, internal lighting, heating and water. People had individual emergency evacuation plans in place which highlighted any support they needed to evacuate the building safely in the event of an emergency.

The kitchen had received a food hygiene rating of 2 stars on 27 August 2024 from the Food Standards Agency. Their report included requirements the provider must adhere to. The deputy manager showed us an action plan confirming (and we saw) that action had been taken to address all the requirements.

Robust recruitment procedures were in place. Recruitment records included application forms with employment histories, employment references, proof of identification, health checks, and right to work in the UK checks. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out.DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

We observed there were enough staff deployed throughout the service to meet people’s needs when required. People told us there was enough staff on duty to meet their care and support needs. Comments included, ‘Staff are supportive’ and ‘Staff are always here 24/7’. A staff member said, “I think there are enough staff to support people, we have good handovers and I’m not aware of any staffing concerns from other staff.”

Training records indicated that staff had completed training in areas such as awareness of mental health, dementia and learning disability, understanding diabetes, equality and diversity, fire safety, health and safety, emergency first aid, food hygiene, infection control, moving and handling, safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Records also confirmed staff were receiving formal supervision with their line managers. A staff member told us, “I am up to date with my training, and I am doing a mental health awareness diploma, so I feel I am well trained. I also receive regular supervision from my manager.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of infections spreading. The provider employed staff to oversee cleaning at the service. We observed that the service was clean, and people were encouraged to clean their own rooms. Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. Training records confirmed that all staff had received training on infection control.

People told us they received their medicines safely and as prescribed. Medicines were administered by trained staff who had completed up-to-date medication competency assessments. A visiting health care professional told us they regularly visited the service to administer prescribed medicines to some people using the service. We saw medication administration records (MAR charts) were completed accurately by staff, with codes for non-administration where appropriate. PRN (as required) medicines protocols were in place to guide staff on when to administer these medicines. Regular monthly audits of medication practices were carried out to make sure medicines were managed safely.

A pharmacist that provided medicines to people at the service told us medicines were well managed.The manager informed them when people had been discharged from the service or when there were changes to people’s medication, they could amend records at their end. Staff accompanied people to medical appointments and always informed them of any changes to people’s medicines.