St Peters Court

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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 63 (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 did not always have a proactive and positive culture of safety based on openness and honesty. There was limited evidence that lessons were learnt. Whilst the provider logged accidents and incidents, it was not always clear that all actions to mitigate risk had been undertaken. We found examples where people had experienced multiple incidents of harm or risk of harm such as repeated falls. There were a number of people who were commissioned for 1:1 support, however we could not always be assured that the appropriate staffing levels were in place. This had also been discussed with the provider by the Local Authority. The provider has since confirmed they have increased staffing levels and improved their oversight around accidents and incident monitoring. We have not been able to assess the impact and sustainability of these changes during this assessment.

The provider worked with people and healthcare partners such as GP’s, pharmacists, and specialist services such as the Dementia Intensive Support Service (DISS). They made sure there was continuity of care, including when people moved between different services.

Feedback we received from external healthcare providers was mostly positive. One healthcare professional told us, “I have come to this care home lots of times, the approach is very good. They take on board what we say here. Staff here are great.”

The provider had systems and processes in place for pre assessment prior to admission at St Peters Court and we saw evidence of pre assessment documentation in place.

We were not always assured safeguarding concerns were reported effectively and raised appropriately with the relevant authorities. We found repeated incidents of a similar nature had not been fully investigated to demonstrate learning and actions taken to mitigate further risk. For example, there were a number of incidents that had occurred between people living at St Peters Court and a large number of falls occurring. The provider has since improved their reporting processes for safeguarding, though we have not been able to assess the impact of these changes at this assessment.

Staff had received safeguarding training and demonstrated they understood their responsibilities in safeguarding people. Staff told us they felt able to raise any concerns. Comments included “I feel comfortable raising concerns or suggestions with management” and “We can raise complaints or concerns with management at any time and they listen to us”. We observed positive interactions between staff and people during our visit. We saw evidence of safeguarding being discussed in staff meeting minutes we reviewed. The provider had safeguarding policies in place.

Feedback from people and their relatives was mostly positive in relation to raising concerns if they needed to. Comments included, “If I had a complaint, I would feel able to raise it directly with staff at the home. I know they would listen and discuss it with me and take any appropriate action” and “If I have any concerns, I know I can talk to any of the staff and any issues will be dealt with in a timely manner.”

The provider had systems in place to regularly review care plans and risk assessments. However, it was not always clear how decisions were made and who had been involved, regarding best interest decisions and mental capacity assessments around certain areas, such as room sharing. We have discussed this with the provider to make this process more robust. The provider has since made improvements to strengthen their processes. We have not been able to assess the impact and sustainability of these changes during this assessment.

We reviewed care plans and risk assessments during our assessment of St Peters Court. We received mostly positive feedback that people and their relatives confirmed they were involved where appropriate in care planning and reviews. Comments included, “I have attended meetings with people involved with [relative’s] care, everyone has been happy to answer my questions” and “Somewhat involved now, previously no.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had regular checks in place for equipment such a slings for hoists and these were up to date and ensured equipment was in good working order.

Staff had been trained in fire safety and fire awareness training as well as fire warden training for specific staff. Staff had also received training for health and safety and areas such as infection prevention and control.

Risk assessment and regular audits were in place and being carried out to ensure the safety of the environment for people and staff. The provider had maintenance staff in place and also used external stakeholders to help support the maintenance of the environment.

The provider had a rota system in place and used a dependency tool to help determine staffing levels at St Peters Court. It was not always clear that the dependency tool was effective in maintaining safe staffing levels. The provider told us auxiliary staff cover 1:1 support when the care staff are on their breaks or if there is carer sickness etc. During our on-site visit we observed auxiliary staff supporting with 1:1 support and when reviewing training records, we identified that not all staff had received the appropriate training to support people with 1:1 support needs. For example, there were a number of auxiliary staff who had not received training in safety intervention training. We addressed this with the provider to ensure all staff had received the appropriate training and they have since ensured all staff have received the required training. We have not been able to assess the impact and sustainability of these changes during this assessment.

Staff told us that they felt the training they received at St Peters Court was good. Comments included, “We are encouraged to request additional training whenever needed to improve our skills and knowledge” and “Training is available at all times with E-Learning and face to face training.” Staff had been inducted into their roles.

We observed staff worked well together and people and their relatives told us they felt there was enough staff at St Peters Court. One relative told us, “I do feel there is always enough staff on duty, because you can always find someone to ask anything.” Another told us, “Staff are always visible here and if you need anyone you can always find someone to help you.”

The provider had recruitment procedures in place to ensure the required checks were carried out prior to staff commencing their employment. We reviewed records for staff which showed that thorough checks had been completed. This 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.

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.

Cleaning audits, monitoring and checks were in place and ongoing and all staff received infection prevention and control training. Staff were observed practicing good IPC during our onsite visit, including wearing appropriate personal protective equipment (PPE). The environment and equipment were clean and well maintained. Staff supported people to maintain their personal hygiene well.

People and their relatives told us they were happy with the cleanliness of the home. Comments included, “The home is clean, bright and modern,” My [Mum’s] room is always tidy” and “There is always cleaning going on around the home, and everything is always put away neatly.”

There were systems and processes in place for the safe management and administration of people’s medicines. Medicines were stored securely. We observed safe handling of controlled drugs and controlled drugs protocols were being followed accordingly.

Medicine administration records showed people received their medicines as prescribed.

Daily temperatures of the fridge were taken and recorded to ensure the fridge remained at a safe temperature.

Staff worked closely with the GP and pharmacist to make sure medicines were managed appropriately.

Training records showed that staff had received the appropriate training to support people with their medicines and annual competencies had been completed for all staff who administer medication. The provider had a medication policy and audits in place including weekly and monthly medication audits.