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 assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 75 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Improvements had been made in analysing concerns about safety and investigating possible themes.

Staff confirmed they knew how to raise their concerns with the management team.

The registered manager told us they used examples of lessons learned from other adult social care settings to help inform service improvement. This ensured the service remained informed about emerging risks, best practice guidance, and opportunities to improve outcomes for people using the service.

The provider had a new system in place to report and record incidents and accidents. This was closely monitored by the registered manager to identify trends and themes. Records confirmed actions were taken following incidents to reduce the risk of reoccurrence and harm to people.

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 new process in place to ensure people’s information was availablein case of an emergency hospital admission. The information was up to date and kept in paper folders, which meant it was easily accessible to staff.

Records confirmed staff contacted external professionals when necessary and acted on their advice and recommendations.

Health and social care professional told us staff knew people well and contacted external professionals appropriately and in a timely manner.

The provider 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 and their relatives knew who to contact should they have concerns and were confident any issues would be resolved. 

Staff told us they knew how to report their concerns to the management of the service and external organisation if required. A staff member told us, “If I was concerned someone was being abused, I would report it to my Team Leader or Manager and, if needed, to the Safeguarding Team, CQC, or the police.”

Records confirmed safeguarding concerns were raised appropriately with the local authority when required.

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 registered manager had oversight of authorisations.

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

People had individual risk assessments in place. Risk assessments and care plans were regularly reviewed and updated to ensure they remained accurate. The provider used an electronic care planning system, which meant when changes were made, these were immediately available to staff involved in people's care.

People told us they felt safe living at the service.

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

People were complimentary about the service and said they liked their bedrooms.

Staff told us they knew how to report concerns relating to the environment.

A staff member told us, “I report concerns directly to the registered manager, who is very proactive in resolving issues with the support of the director. For example, when I noticed that a resident's air mattress was not functioning properly, I reported it immediately to the [registered] manager. The issue was addressed without delay, and the resident's mattress was promptly replaced to ensure their comfort and safety.”

The provider had a health and safety improvement plan in place to ensure they, identified risks, implemented necessary actions, and monitored progress effectively to continuously improve safety standards.

People had Personal Emergency Evacuation Plans (PEEPs) in place. PEEPs provide staff and emergency service personnel with information on how people would need to be supported to safely evacuate in the event of an emergency.

The provider used external contractors to service the fire system and to undertake checks, including equipment checks. This meant they had been carried out by qualified individuals. Following recent water hygiene and fire safety inspections, the provider received a list of required actions. During our inspection, we found that most actions were taken and following our feedback, the provider arranged for the remaining necessary work to be completed.

The provider 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.

The provider made improvements in their recruitment practices. Staff had 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.

Staff received training relevant to their role. Records showed staff had regular supervisions, spot checks and team meetings. A staff member said, “I have regular one‑to‑one supervision with a senior member of staff. These sessions are helpful as they provide guidance, feedback, and an opportunity to discuss any concerns or development needs.”

We observed kind interactions between staff and people, for example when people were supported with their lunch. We also observed call bells were answered promptly and without a delay. Records confirmed this was regularly monitored.

Records showed staff’s performance was checked outside of normal working hours. The registered manager confirmed this will be continued to ensure effective oversight of care delivery across a 24-hour period.

The provider assessed and managed the risk of infection.

We observed communal areas and people’s bedrooms to be clean, well maintained and free of clutter.Housekeeping staff were visible throughout the inspection.

People told us they appreciated their bedrooms were always well maintained and cleaned regularly. A relative said, “I see the staff cleaning constantly. I am very happy with the hygiene and cleanliness of the bathrooms, bedroom and public areas.”

The kitchen was clean and well stocked. The service had achieved a 5 rating in relation to food hygiene. This meant food safety was assessed as being ‘very good’.

Staff confirmed they had access to Personal Protective Equipment (PPE). A staff member said, “We have the PPE we need, including aprons, gloves and masks. If we run out during our shift, we go to the store cupboard and replenish our stock.”

Staff had completed infection prevention training, and the provider had an up-to-date policy in place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff had medicines training and their competencies were checked regularly. We observed the medicine room to be clean and well organised.

We also observed staff administering medicines safely and seeking people's consent before providing support with their medicines.

A person told us they received their medicines in a way that met their changing needs, as they were unable to remove tablets from the blister packaging independently. This meant they were able to take their medicines safely and as prescribed, while maintaining as much independence as possible.

Some people were prescribed ‘as required’ medicines. Guidance was in place to help staff administer these medicines safely. 

People only received covert medicines in accordance with legal requirements and in consultation with relevant professionals.

Records confirmed the provider worked closely with healthcare professionals in relation to medicines management. Any changes in people's health needs were communicated promptly to relevant professionals to ensure medicines were reviewed and amended where necessary.