St Anne's 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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We have identified a breach of legal regulation in relation to safe care and treatment. The provider had failed to ensure risks to people were properly assessed, equipment was maintained, and medicines were managed safely. This had placed people at risk of avoidable harm.

This service scored 59 (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 did not always analyse concerns about safety and did not always investigate possible themes. Lessons were not always learnt to continually identify and embed good practice.Accidents and incidents were recorded on the provider’s electronic planning system; however, the service did not always review the information and use this to learn lessons and change practice. This had meant they were not proactive in their approach to learning. Staff told us they knew how to report concerns. Health and social care professionals were positive about working with the service and told us they contacted them about people following events such as falls.

The service did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including for people’s care needs in the service and when people moved between different services.People’s care records were not always accurate and up to date which meant there was a risk of them not receiving the care they needed. For example, the provider’s electronic care planning system could generate a summary of people’s needs, however this had not always been accurate. The service had a strong relationship with external health and social care professionals, however, information shared was not always accurate. We raised this with the manager and registered manager who took action to address this concern. Staff told us they knew people well, understood their needs, and had communicated those with external services, including hospitals.

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.People told us they felt safe living at St Anne’s Court. A person said, “I feel safe and settled, this will do me for the rest of my life.” There was a safeguarding procedure in place, underpinned by a policy. Staff knew how to raise concerns within the service and externally, they told us they were confident in the manager to follow up and act on the information. Regular safeguarding training had been completed by staff. Records showed safeguarding concerns had been raised to the local authority. In addition, notifications had been made to the Care Quality Commission as required. A statutory notification is required by law, to notify us of any significant events, allegation or injury within the service. We observed staff working with safeguarding in mind, when raising concerns to the manager. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the DoLS, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The manager had oversight of authorisations.

The service did not always work well with people to understand and manage risks. They did not always record care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.Risks to people were not always identified, assessed and mitigated. Some risks within the environment had not been assessed, this had place people at avoidable harm. For example, people's risk assessments were not always person centred and detailed, this meant people were at increased risk of avoidable harm. They contained some generic information about signs and symptoms of health conditions, instead of being related to the person. We found control measures were not consistently carried out. Staff told us they did not always follow the risk assessments as it was not always related to the person’s needs. We raised these concerns immediately with the manager and registered manager. They took action to address the shortfall. We observed staff working in safe ways when supporting people with moving around the service. People told us they felt safe.

The service 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.The provider did not always ensure people were safe from risks within the environment, this had included equipment and fire safety. Equipment used to support people to move had not always been maintained in accordance with the relevant legislation, this had placed people at increased risk of avoidable harm. Fire safety arrangements had been assessed, however, there was conflicting information. The provider could not be assured they were working to the safest plans for evacuation because information was conflicting. We shared this concern with the local fire service who arranged a visit to the service. Utility checks had been completed, however the process to ensure these were carried out in line with the related legislation and their policy was not always effective. For example, our observations confirmed our findings. We raised our concerns with the registered manager; they worked to address the shortfalls and told us they would strengthen the process. People told us they enjoyed spending time both in the communal areas and their bedrooms.

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. People were supported by enough staff to meet their needs. The provider considered people’s needs and dependency to calculate staffing levels. People said staff came when they called them using their call bell. Observations made during the inspection did not raise any concerns about staffing numbers. The service had a thorough induction, shadowing, competency checks and ongoing support process in place. Training was in accordance with good practice guidelines for staff who worked with people who required care and support. A recruitment process was in place to ensure the required checks were completed prior to staff commencing their employment. However, this was not in compliance with legislation for the safe recruitment of staff. This meant some required checks had not been carried out, for example, exploration of employment history and health screening. The provider had completed other checks such as an enhanced Disclosure and Barring Service (DBS) check 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 manager and registered manager sought to rectify this shortfall during the inspection.

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.People and their relatives told us the service was clean and hygienic. Staff received training in infection prevention and control. Dedicated staff were employed and ensured the service was clean. We observed the service to be clean and maintained, there was a continual improvement plan for redecoration and refurbishment. Personal protective equipment (PPE) was worn appropriately by staff. Safe infection prevention and control procedures were in place and were supported by the provider’s policy. Infection control procedures were in line with good practice guidance. Staff had plentiful supplies of cleaning materials, products, and PPE.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.The provider had not followed their medicines policy to ensure medicines were managed safely. For example, the policy required a running balance of medicines was documented. This had not happened. This meant the provider could not be assured medicines were given in accordance with the prescriber’s instructions. Where medicines had special arrangements, such as covert administration, the required authorisations were not always in place, for example, from the GP. Staff had received training in supporting people with their medicines, they told us they were confident in carrying out this role. Where medicines required stricter controls or were only given occasionally, guidance was in place to ensure they were administered consistently. People were supported with kindness when having their medicines. People told us staff supported them with their care, and this had included ensuring they had their medicines.