St Martha's

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 did not assess enough quality statements to rate this key question. At this assessment the service has been rated 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 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.

Staff knew what incidents to report and how to report them. The registered manager shared learning with staff through team meetings, supervision and staff communication channels.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure they could take appropriate action to mitigate these risks. They told us, “Safety alerts are circulated to all unit managers and deputies. We check if it applies to us and we store them on email and with the governance team. This week a medicine was affected, these were removed and returned to the pharmacy.”

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 provider had a robust admissions policy. The registered manager described how they assessed people to establish suitability and compatibility prior to moving in. Some people were supported to visit prior to moving in, and the provider conducted introductory video calls with people if they preferred. The registered manager told us, “People are fundamentally part of the assessment. We engage family and carers through that process; family can visit independently as well if they choose to.”

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 told us they felt safe living in the service and staff knew how to protect people from abuse and who they would report concerns to, both internally and externally. The registered manager followed the correct reporting process and informed all relevant agencies of concerns.

Where restrictive practices were in place we found, restrictions were kept to a minimum. Where required, Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions placed on people to keep them safe.

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

Staff knew people well and people told us they were involved in developing their risk assessments. People were supported to manage risk while maintaining independence and the service promoted positive risk taking. For example, people were assessed for risks of choking and risks relating to medical conditions.

The registered manager described how they had worked with a person, their relative and healthcare professionals to ensure the least restrictive action was taken to support the person safely. They told us people’s rights were paramount.

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

Environmental risk assessments including fire safety risk assessments were completed and checks made of equipment to ensure it was safe to use. Regular audits were undertaken to ensure the environment and equipment remained safe to use including gym equipment. Any concerns were reported to the management team or appropriate person for further action.

Staff attended regular fire evacuation drills to ensure they could safely support people out of their home in the event of a fire. However, not all staff had attended a fire evacuation drill. The Health and Safety Officer told us, “We are mitigating that not all staff have attended [fire evacuation’s] by providing 3.5 hours face to face training, I go through scenario evacuations and the equipment with staff.”

The provider made sure there were enough qualified, and experienced staff. They made sure staff received effective support, supervision and development.

However, staff recruitment records did not always show all appropriate checks or the decisions the provider told us they had made to ensure only appropriate staff were recruited. We spoke with the registered manager about this who assured us processes were being put in place to make these improvements and to mitigate risks.

Training monitoring records evidenced most staff had completed all their statutory and mandatory training and competency assessments to ensure they were able to meet people's individual needs. Staff had attended additional training relevant to people’s individual needs.

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 attended Infection Prevention and Control (IPC) training. We observed staff wearing appropriate personal protective equipment as required throughout the inspection. We reviewed cleaning schedules which were consistently completed. People and their relatives told us the service was clean, and we observed this.

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

There were suitable arrangements for ordering, storage and disposal of medicines, including those needing cold storage and for controlled drugs. Temperatures were monitored to make sure medicines were stored correctly and would be safe and effective.

People received their medicines safely in the way prescribed for them. Some people’s care plans would benefit from further person-centred details around some medicines being prescribed when required. However, staff knew people well and were knowledgeable about their medicines and needs. Nurses had updated training and regular competency checks to show they gave medicines safely.

Records were in place to show that risks were considered for higher risk medicines such as anticoagulant blood thinning medicines and flammable topical preparations.

Robust medicines policies were in place to provide guidance for staff. Medicines audits took place to identify improvements and were discussed at regular governance meetings to ensure any necessary actions were taken.