St Audrey'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

The provider had not always managed risks to people well. They did not have a robust process to monitor incidents or safeguarding concerns and ensure learning was shared. People’s medicines were not managed safely. The provider had not ensured staff were recruited safely and had the appropriate training and competency for their roles. Staff supervisions and competency assessments had not been completed. The environment was in a poor state of repair and communal areas were not clean. The provider had not ensured there were enough domestic staff to maintain the cleanliness of the whole home. The provider’s processes for communicating with people, their relatives and other health professionals were not effective.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s relatives said they were informed if serious incidents occurred but felt communication could be better for minor concerns. A relative said, “When it is more dramatic, they are on the phone to me. I noticed on 1 of their records [person] had a fall a while ago, but I wasn’t aware of it.” Another relative said, “They do if there is a problem.” We were also told, “Anything like if condition worsens, get medics they do let me know. As far as action plan, I’ve had a few emails but not as much as I had expected with [person’s] condition as it is.”

Staff told us information was shared following incidents. A member of staff said, “This has improved recently, though it was not consistently done in the past.” Another staff member said, “I am always informed about the new updates and changes that are important and require immediate attention via handover, email etc.” We were also told, “Information is shared during handover by shift leaders.”

Staff did not escalate concerns documented in people’s records. We found incidents in daily logs and information in monitoring charts which had not been reported. This meant no action was taken when people had not eaten or drank enough, for example, which placed them at risk of harm. The provider had trackers to monitor incidents which showed the initial report and action taken at the time. There was no evidence of investigation, outcome, further action, sharing learning or analysis for themes. Therefore, we were not assured the provider had full oversight of incident management.

People’s families told us their relatives had been referred to some other services but felt this would be more effective if there was a permanent manager. A relative said, “If there was a manager, it might happen a bit more. The chiropodist visits every few weeks and I ask for [person] to be on the list but have checked their feet and not happy.”

The provider had input from the GP via weekly rounds. They had not attended Multi-disciplinary Team (MDT) meetings for several months but planned to attend the next 1. The provider said, “The majority of the meetings by [the surgery] over the last 6 month have been cancelled, the next scheduled MDT is October 2024, and we will be participating. We do however continue to work with other health professionals and have weekly GP ward rounds with outcomes available via email.”

We received conflicting information from professionals regarding attendance at MDT meetings. A professional told us, “The care home refers their residents and attend our PCN MDT regularly. Because of a small size of care home, they might not have discussed so often, but they always communicate well with our PCN project co-ordinator whether they have residents to be discuss.” We were also told, “There has previously been minimal engagement between the Multidisciplinary team and the home for monthly MDT meetings often cancelled as the home has had no one to discuss or the GP surgery has cancelled. There has been no MDT this year with St Audreys.”

People’s records lacked evidence of referrals to/input from other professionals. For example, 1 person’s record indicated they should have been referred to occupational therapy in July 2023, but this had not been done. There was also no evidence of support to find a dentist for a person whose teeth were not in good condition.

Most people felt safe living at the service and confirmed staff checked on them regularly. A person said, “Oh, yes. The girls are all nice.” Another person said, “Yes, I am happy and safe. They are lovely people.” However, we were also told, "It's terrible. I feel terrible."

Staff understood their responsibilities around safeguarding. A member of staff said, “Abuse of any kind I would report to the manager and if not acted on in 24 hours I would raise again.”

We observed very few interactions between staff and people during our visit, but no safeguarding concerns were identified.

The provider did not have a robust process to monitor safeguarding. We reviewed their tracker and found it lacked detail of what happened, action taken and learning shared or the outcome. There were 15 safeguarding events on the tracker; 5 had not been reported to CQC.

People and their relatives were not involved in reviews of their needs. A relative told us, “I’m not aware when they review it; I’m not involved in the process. I would like to be, but it always seems to happen outside of me.” Another relative said, “Right from the start they said we would have regular reviews/meetings, but I’ve never really had anything like that.”

Staff were able to describe people’s needs and understood how to manage risks to them. A staff member said, “We have to keep an eye on [person’s] skin and put cream on it.” Another member of staff told us, “Most of the [people cared for in bed] are at risk of pressure sores. They need to be turned, re-positioned, sometimes you sit them up or get them to the armchair. So they don’t get pressure sores.”

We observed very few interactions between staff and people during our visit. Therefore, we did not see any evidence of people supported to manage risk. However, the lack of social interaction means there was potential risk of social isolation with lack of stimulation.

People’s records did not always include assessments for all risks to them. People were at risk of malnutrition and dehydration. Their records had not always been updated to reflect the risk and monitoring charts were not effective. We reviewed fluid charts with no targets and quantity of food eaten unclear. Where intake was low no action was taken by staff and people we reviewed had experienced significant weight loss and dehydration. Pressure care was not managed well. We found some people at risk of skin breakdown did not have risk assessments and information was unclear about frequency of re-positioning.

People’s relatives told us there was room for improvement in some parts of the premises. They described having to raise concerns quite firmly before they were addressed. A relative said, “It shouldn’t really have got to the point where I had to flag it.”

The provider told us they had a refurbishment plan, and we saw documentation to support this. There were plans for some bedrooms to be decorated and wardrobes to be fixed to walls. This put people at risk of harm from wardrobes being pulled or falling on top of them.

We observed bathrooms and communal areas in a poor state of repair. This included bathrooms/corridors with scuffed/cracked doorways and shelves. The kitchenette had broken cupboard doors and the drawers on some people’s chest of drawers were broken. We found people’s wardrobes were not fixed to the walls.

The provider completed audits to monitor the safety of the environment. Following our feedback, the provider shared quotes and invoices to confirm the planned improvement work. However, we did not receive a timeframe for completion of this work.

People’s relatives felt there were not always enough staff with the appropriate training to meet people’s needs. A relative said, “[They] could have had slightly more training. They were aware of dementia generally but don’t think they fully understood the challenges…They learned very quickly.” We were also told, “They are all nice people, nice staff, it just seems they are a bit understaffed and could do with a few more.” Most people we spoke with said staff provided care which met their needs.

The provider had not ensured there were enough domestic staff to maintain the cleanliness of the home; they confirmed there was 1 staff to clean the whole building. They focused on people’s rooms, meaning the communal areas were not clean. The provider confirmed staff competency assessments had not been completed for moving and handling and medicines competency assessments had not been completed in a timely way. “We have completed previous medication competencies, but they need updating as not been completed in line with expected timescales, training has been arranged for senior staff to enable new competencies to be updated. In relation to the moving and handling competency this is just being reviewed ready for senior to be able to complete them in due course.” Staff felt there were enough staff to care for people safely, but they would like more training. A staff member said, “There's always enough number of staff in early, late and night shifts. Staff shortages are solved promptly.” Another staff member told us, “I think we can do better in terms of training.” We were also told, “I’ve learned along the way. I've got to redo my food hygiene in October. We are all due training refreshers. I will be doing all that.”

During our visit, there appeared to be plenty of staff around. However, we did not observe any interactions between staff and people who were sitting in the lounge. There was 1 domestic staff cleaning people’s rooms during our visit. This was the norm and not enough to ensure the whole home was kept clean.

The provider had not ensured staff had the appropriate training and competency for their roles. Staff supervisions and competency assessments had not been completed. We reviewed the staff training matrix and found only 1 night staff had completed training in administering medicines. There were no courses on the matrix related to catheter care, behaviour support, end of life care, pressure care or any other conditions people may have. Staff were not always recruited safely. A staff member who had just arrived in the country did not have a police check from the country they came from or evidence of required level of English. Another staff member had not provided full employment history. Following our site visit, the provider obtained explanation of the gaps in employment history.

People and their relatives felt the home was kept clean and confirmed staff wore Personal Protective Equipment (PPE). A relative said, “It’s good – the cleaner is always there; [staff] is very conscientious.” A person told us, “The environment is generally fine - clean and maintained." Another person said, “They do wear gloves and all the gear.”

Staff told us there was only 1 staff member who did the cleaning during the day. We were told this had been the case for a very long time. Night staff raised concerns about having to clean in addition to providing care and some specific concerns about hygiene of the main kitchen. A member of staff told us, “Cleaning the main kitchen in between providing personal care may not, in my opinion be hygienic, as some individuals may not practice good hygiene and cross contamination could take place e.g. handling / washing dishes and pots in between pad changes and attending to buzzers.” We were also told, “The kitchen is left in a mess where they use to service dinner. The 1 by the diner gets cleaned on a continuous basis because the residents go there. The main kitchen is my concern – night staff have to clean it, and it is around not having a proper chef.”

We found communal areas were dirty. This included bathrooms and toilets, dusty bannisters, skirting boards and light switches. The kitchenette was in a poor state of repair with cupboard seals missing, worktop edges scuffed and dirty shelves in the fridge. There was also a filthy dishwasher which we were told was out of order and was removed following our feedback.

The provider’s Infection Prevention Control (IPC) audit and housekeeping audits were not effective. We reviewed the most recent, which had been completed March 2024. The IPC audit described the premises as extremely clean with an enhanced cleaning schedule. Neither identified the issues we found.

People’s relatives were happy about support with medicines. A relative told us, “[Person] takes them very well…they are very good at encouraging [person].” Another relative said, “[Staff] are on the ball with it all.” A person told us, “Yes they are good with all that.”

Staff told us 1 person self-administered their medicines; staff were putting the medicines in a dossett box for the person. We fed this back to the provider, and they advised, “Up until recently medication trained staff where filling [person’s] dossett box weekly, this process was ceased with immediate effect once identified and [person] is now having their medication administered by staff.” Night staff confirmed they administered PRN medicines, which are medicines taken as and when required. However, we found night staff had only completed medicines awareness training, not administration. We found some issues with medicines during our visit and were not assured staff would take action to address these. This included medicines in the controlled drugs cupboard which were not in the controlled drugs book. Staff were not able to tell us how they identified errors in medicine administration and lacked understanding about PRN medicines. However, they showed us how they knew what to administer and when via the electronic medicines administration record, used PPE and ensured all doors were locked/trolleys secure.

The provider had not ensured people’s medicines were managed safely. We found creams were not signed for on Medicine Administration Record (MAR) charts and some PRN appeared to be administered regularly. On 1 day a tablet had been administered 3 times when it was for a maximum of twice daily. We reviewed the most recent medicines audit, which was completed in February 2024. This meant it was not done monthly as stated in the medicines policy. We found it had not identified the issues we found such as lack of staff competency assessments, secondary dispensing and PRN protocols not updated/reviewed. This meant mistakes were made, and not identified, because the provider’s processes were not robust.