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.

This is the first assessment for this service. This key question has not yet been rated.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We did not look at Learning culture during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

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 established effective processes for safety and continuity of care through a collaborative, joined-up approach that involved people along with staff, communities and other partners. There were clear systems and processes in place to refer people to external services, which were applied consistently and a clear strategy to maintain continuity of care and support.

When people were not able to participate in the care planning process due to their cognitive abilities, staff had attempted to convey their views in their care plans, including information gathered about peoples life histories and preferences from relatives to ensure their views were always considered and respected. Formal processes including regular residents, professionals and staff surveys were in place to gather the views of people who use services, partners and staff. Information gathered in feedback was used to drive improvements and innovation.

Staff worked collaboratively across services to understand and meet people’s needs. Comments included: “We have nursing units upstairs in the building giving an opportunity for patients to transition and benefit [from] the continuing care. We are getting people a lot more active, and they are doing more. Trying to push forward community-based projects and therapeutically, that is beneficial” and “We regularly have feedback from a survey and [people] comment on things such as food, cleanliness and activities. Surveys are anonymous and have widened the way they can give feedback. Anonymous surveys in the café and feedback on tablets they can submit”. Staff told us the GP visited every Tuesday to review medical concerns and monitor people’s healthcare needs.

We received feedback from people and their relatives about maintaining continuity of care and their involvement in creating and reviewing people’s care records. We saw people were able to ask for changes to their care plan, and had open discussions about their support needs. We received positive feedback from health and social care professionals about maintaining partnership working to ensure safe systems of care, in which safety is managed, monitored and assured. Comments included, “The referrals and updates my team receive from St Martha's are appropriate and timely, and the staff are always professional and responsive; never had any problems working with them. They know the patients well and give me very useful feedback even on small but important aspects of their mental and physical health, and that applies to a range of professionals, and I have spoken to quite a few!” and “I'm always impressed with how the [staff] deal and manage the patients. There have been circumstances where patients have arrived from acute trusts and community settings, often declining in physical health (on the background of mental health), yet the supportive care on Tulip Unit and Daisy Unit appears to really enhance their recovery in a positive manner.”

We did not look at Safeguarding during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

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.

People’s needs and individual risks were assessed before they started to use the service and were added to their care plans as needed. Relevant health and safety concerns were included in people’s care plans, which were detailed, and person centred. Risk assessments were created and maintained within the providers electronic care planning system. Care plans and risk assessments were reviewed and updated regularly, or as things changed. Staff involved people in decisions about their care whenever possible, and we saw evidence of input from people’s relatives and representatives.

Staff told us they had enough information about people’s support needs and how to mitigate risks people faced every day to keep them safe. Comments included: “Care plans are individually tailored including goals. Families are heavily involved and from [the] day of admission we put down what we can offer, and they set goals with us, and we review each milestone. We invite external stakeholders and families, so it is a collaboratively approach” and “We will have a [pre-admission] assessment, where we will get the information [about people’s individual needs] before they are admitted. After the admission we help create a care plan for [each person].”

Professionals confirmed this: “We have had numerous discussions about the ways of improving the quality of [people’s] life by introducing certain modifications and monitoring the progress. I am always pleased to see that there are opportunities for the families to get involved as well.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our SOFI, we observed people were able to move around their units freely but required staff intervention to access the kitchen. People were not able to help themselves to snacks or hot drinks throughout the day and relied on staff to access them. The provider told us staff made risk-based decisions based upon whether people were safe to help themselves to snacks and hot drinks. These risk-based decisions were made on a daily basis for each individual to ensure their needs were fully met. For example, some people were on fluid restrictions. Staff were respectful and attentive to people’s needs and we saw them responding swiftly to their needs. We did not see any evidence of pictorial menus which may be useful to some people, particularly those living in Daisy Unit. Following the inspection, the provider told us they were planning on developing pictorial menus with the catering department.

Staff recognised people's non-verbal and behaviour cues, offering reassurance and using gentle redirection and distraction techniques. We observed kind, patient and unhurried interactions between staff and people. Staff appeared to know the people well and people appeared calm and comfortable around staff. People could access their bedrooms and communal toilet using a soft wrist fob. However, not all people that we met had these and not all were cognitively able to do so.

All bedrooms had viewing panels which were kept closed and staff only opened these when completing day and night observations. We saw 1 person’s viewing panel opened when they were in their bedroom not fully dressed. We reviewed that person’s care plan which confirmed this was their choice.

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.

Risks to people’s immediate safety in the environment were overall well managed, such as minimising trip hazards. Bedrooms had aspects which were ligature proof, however this was not consistent and so did not reduce risks of ligature incidents and made the environment less homely. For example, ligature proof swing doors were on ensuite bathrooms, however wardrobe doors could be closed.

The provider had not always followed good practice guidance to assess how each person living with dementia could orientate themselves in their surroundings. Contrasting colours had not been used and some people did not have personalised items to easily identify which room was theirs. People were able to personalise their bedrooms with furniture, photographs and belongings from home. However, bedrooms walls were decorated with murals which had not been chosen by people and staff told us some people found these murals disturbing and confusing. Corridors had repeating features, which made orientation independently more difficult.

Wall murals in the lounge could be potentially disorientating and overly stimulating for people and did not meet best practice guidance. Although there were several signs around the unit to support people to locate toilets, the murals were disguising communal toilet’s door. As a result, some people were not able to identify the toilets and had to rely on staff assistance with personal care.

The provider had not always considered the impact of the physical environment on people’s wellbeing and levels of distress. At the time of the inspection, the environment was noisy, with overstimulating murals patterns. We saw signs directing people to quiet rooms in both units. However, staff told us that designated quiet rooms on both units were converted into bedrooms and dining rooms were now used as quiet rooms.

We observed an incident on Tulip Unit. A number of people became increasingly distressed over loud noise levels and environmental overstimulation, however, they were not able to remove themselves from the situation. The dining room, converted to the quiet space was in close proximity to the main lounge. Effectively there was nowhere quiet for people to go and avoid overstimulating environment. This can have a longer term negative impact on their mental and physical wellbeing.

Staff told us people were not able to close the viewing panels from inside their room.

We did not look at Safe and effective staffing during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Infection prevention and control during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

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

Medicines were stored safely, storage conditions and stocks were monitored and managed appropriately. There was safe and robust oversight of medicines administration, and staff followed good infection control and consent practices when administering medicines.

There were clear plans in place for the use of medicines to support people’s anxiety and agitation. Some ‘as required’ (PRN) protocols for medicines lacked detail, however the staff understood people’s presentation, medical needs and when to administer these medicines. We were assured people would be supported with these medicines safely.

There was guidance for staff around use of covert medicines, which ensured staff knew to offer medicines overtly first and how to manage refusals for people who lacked capacity related make decisions related to these medicines. Although records did not reflect that best interest decisions were made for each medicine individually, the manager agreed to take action with the GP to resolve this.

Staff had training and up to date competencies related to medicines administration, there was information available to them about the medicines and good GP support to ensure people’s medicines were reviewed regularly.

People told us they had their medicines when needed, and we observed staff offering pain relief and other PRN medicines to people based on their presentation or when they requested support.