St Ann's Lodge 1

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

Safety events were investigated and the lessons learned were used to improve the safety of the service. People’s safety was managed well as soon as they started using the service because plans were put in place to ensure people received safe and appropriate care. Staff knew how to safeguard people from abuse and what action to take to protect people. Risks to people were managed well because staff understood how to reduce risks to keep people safe from injury or harm. There were enough staff to support people and meet their individual needs. Staff undertook relevant training to meet people’s needs. Staff received regular supervision to continuously learn, develop and improve their working practices. Recruitment processes were robust and checks were undertaken on staff to make sure they were suitable to support people. People were supported to live in a clean, hygienic environment, which was regularly checked and maintained to ensure risk to people was minimised. Staff followed current practice to ensure infection risks to people were minimised. Medicines administration arrangements had been improved and the provider was no longer in breach of regulation. Staff record keeping had improved and better information was available to them about people’s medicines. People now received timely support with their medicines which were administered as prescribed.

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.

People’s safety and wellbeing was a priority for the service. Senior staff took prompt action to address safety events when these arose. The learning from safety events was used to improve staff working practices, reduce further risk and keep people safe.

Staff understood the importance of prompt reporting of safety events to senior staff. Staff were confident that senior staff would take timely and appropriate action to reduce further risk and keep people safe. Senior staff told us people’s safety and wellbeing was a priority. They encouraged staff to be open and honest and to report safety events when these arose, so that action could be taken to keep people safe.

Systems to support prompt reporting, recording and investigation of safety events had been improved and were now more effective. These had been updated following a recommendation we made at our last inspection. Learning from safety events was used to support staff to continually improve their practice and provide safe, high quality care to people.

People’s safety was managed well from the moment they started to use the service. Prior to moving in, information was obtained about people’s individual needs and risks to their safety. This was used to develop care and risk management plans to ensure people received safe and appropriate care and support from the moment they moved in. A relative told us, “Everybody is looked after based on their specific needs.”

Senior staff made sure people, and others involved in their care, were involved in assessments and planning of their care and support, to aid a smooth and safe transition when they started to use the service. The deputy manager told us, “The initial assessment is crucial and we would involve all the relevant professionals and people involved in people’s care to get as much information we can get about the person and we take a person centered approach to make sure we put the person at the heart of everything. We will do risk assessments and risk taking plans with people so we know what the risks are to people and we can manage these. We make sure all the relevant healthcare professionals are in place for the person so that the person’s whole needs are considered.”

Partners had positive experiences of working with the service to ensure safe systems of care were established and maintained to meet people’s needs and keep them safe. A healthcare professional said, “I found the staff at St Ann’s Lodge were very supportive of the assessment process and open to new ideas.” Another healthcare professional told us the staff team engaged with them well during reviews of people’s health and medical needs and communication was good.

Systems were in place to obtain information about people, their individual needs and risks to their safety to ensure people experienced safe and appropriate care from the moment they started to use the service. People, and others involved in their care, were involved in this process to enable senior staff to have a detailed overview of people’s needs and safety risks and how these needed to be managed.

Staff supported people to live in an environment where they were protected from the risk of abuse, neglect, bullying or harassment. People and relatives told us there were open and trusting relationships with the staff team which meant people could raise concerns without fear. One person told us, “No one makes me feel bad…I feel quite safe and we all get on.” Another person said, “I feel safe with the staff. They are nice and kind.” A relative told us, “I do think [family member] is safe. I feel it’s a good place for him.” Another relative said, “Yes, we think [family member] is 100 per cent safe. We think so because we are able to go any time without it being announced and we just go in and the door is open and the atmosphere is always so welcoming…it’s a home from home, not an institute. We were looking for quality care for [family member] and she has that.”

Staff understood their responsibility to safeguard people and received relevant training and support to do so. A staff member told us, “Safeguarding is about protecting people from abuse. I would talk to managers and let them know if I see anything concerning.” The deputy manager said, “If staff see something they should report this straight away. Then the management team would investigate this straight away. Staff have been trained in safeguarding and whistleblowing.”

The atmosphere at the service was calm, relaxed and homely. People looked comfortable and at ease with staff. Staff were friendly, yet respectful, and interested in people’s wellbeing, asking how people were and offering help if people needed this. Staff were attentive and alert to any changes that might indicate people needed reassurance to reduce any anxiety or discomfort they might be experiencing.

Systems were in place to help staff identify and report safeguarding concerns to the relevant persons and agencies. The senior staff team understood their duty and responsibility to work in line with the service’s policy and procedure for safeguarding people. This included making timely referrals and working proactively with agencies to ensure people were safeguarded from further risk. The service was working within the principles of the Mental Capacity Act. Appropriate legal authorisations were in place to deprive people of their liberty where this was deemed necessary to ensure their safety.

Risks to people were managed well and people were able to do the things that mattered to them. One person said staff kept them safe when they were out doing activities in the community. A relative told us, “[Family member] has lots of activities that he does and he goes with staff to keep him safe…the staff are very good at keeping any eye on him and making sure he’s safe as he is not aware of dangers.” Another relative said, “They make sure [family member’s] food is pureed and mashed and she is watched closely when she has her meals.”

Staff understood risks to people and how these should be managed to keep people safe. A staff member told us, “We follow people’s care plans and risk assessments and that tells us how to keep people safe. We wouldn’t do an unplanned activity with someone if we didn’t know what the risk was. I try and get people to do as much for themselves as possible so they have independence and control but with my support if needed.” The deputy manager said risks to people were monitored and reviewed at regular intervals. They told us, “We check people’s risk assessments every six months but would review this sooner if there are any changes in people’s needs.”

People moved freely around the service and spent their time as they wished, with no unnecessary restrictions. Staff were aware of where people were and remained present and available in case people required their assistance.

Systems were in place to ensure risks to people were continually assessed, monitored and reviewed. People’s care records contained information and guidance for staff on how identified risks should be managed to keep people safe from injury or harm.

People were supported to live in a safe environment, which was regularly checked and maintained to ensure risk to people was minimised. A relative told us, “It’s very safe there. Things are catered for people, like the doors are wider.”

Staff understood how to minimise risks posed by the environment and equipment to keep people safe. A staff member said, “I’ve been trained to use a hoist and comfortable using it. I make sure all the areas are clear from obstructions. Any spillages are mopped up and no sharp objects lying around.” The deputy manager told us they undertook regular checks of the environment and equipment to make sure they were safe.

The layout of the home supported people to move around freely. The environment was clean, tidy and free from slip or trip hazards. Adaptions had been made to support people’s sensory needs. Staff were confident using equipment when supporting people.

Safety systems and equipment used at the service were maintained and serviced at regular intervals. Senior staff undertook health and safety checks of the premises at regular intervals. Prompt action was taken to address any safety concerns identified through checks. This helped to ensure the environment, and equipment used, remained in good order and safe for use.

People experienced continuity of care because the staff team were experienced, trained to meet their needs and knew them well. A relative said, “The staff are very well trained. I watch the way they support [family member] and it is good and they are so careful. I’ve got no fears.” Another relative said, “[Family member] is always assisted with care and always kept immaculate.” There were enough staff to support people to undertake activities and events of their choice which ensured people had consistent and well maintained routines. A relative told us, “[Family member] goes disco, swimming and other things as well. He has a very busy life. That was his routine before he went there and this has been continued and maintained for him which is so important.”

Staff received relevant training and supervision to support them in their roles. A staff member told us, “I am in my training period right now. I have been given training by the managers here. We have been given a link to complete courses online. I have had a supervision meeting with the manager and everything is good here. They are very nice managers.” Staff were allocated enough time to undertake their duties and meet people’s needs safely. They worked well together as a team to ensure people’s needs were met. A staff member said, “I think there is enough staff here. I have enough time to do my work. The team work is good and very important as we can’t do anything for people if we don’t work together. Everyone is supportive.” Another staff member told us, “I think there are enough staff. There are plenty of staff to do activities and take people to appointments. I get enough time to do my work. Team work is pretty good.” Senior staff told us staffing levels at the service were reviewed regularly to make sure there were always enough staff to meet people’s individual needs.

Staff were present, available and provided care and support to people when they needed this. People did not wait long to receive care and support from staff. Staff were observant when people were moving around and made sure people remained safe at all times.

The provider operated safe recruitment practices so that only suitable staff were employed to work at the service. There were enough staff to meet people’s needs. Staffing rotas were planned based on people’s dependency and individual needs. Staff were provided with regular and relevant training to meet people’s needs. They were supported through a programme of induction, supervision and appraisal to continually learn and develop in their roles.

People were supported to live in a clean, hygienic environment and infection risks were managed well. A relative told us, “It's warm, inviting and friendly and happy. It’s always clean there. [Family member’s] bathroom is clean and tidy.” Another relative said, “The environment is very clean always…[family member’s] room is always clean and her bedding is done weekly. It’s never been a concern.”

Staff received relevant training and knew the processes to follow to minimise the risk and spread of infection. They told us they had access to resources and equipment to help them reduce infection risks. A staff member said, “We have lots of personal protective equipment (PPE) and this is available around the home.” Senior staff made sure there were enough stocks of PPE for staff to use and regularly checked staff’s competency in managing infection risks at the service. The deputy manager said, “We have plenty of PPE for staff and good level of stocks and we do mini training sessions on infection control and we do this with people as well…we do audits to check records, staff practice and cleanliness and hygiene around the environment.”

The environment was clean and hygienic. Staff wore appropriate PPE when this was required. Handwashing guidance was displayed to prompt good hand hygiene practice. Bathrooms and toilets had hand wash, hand towels and sanitiser readily available to support this practice. Food preparation areas were clean and clear. Food in the fridge, freezer and cupboards was in date, clearly labelled and stored appropriately.

Arrangements were in place to manage infection risks. Staff were trained in infection prevention and control and basic food hygiene training. There were sufficient supplies of PPE for staff to help them minimise infection risks. Staff maintained cleaning and food safety records to provide a clear audit trail of actions taken to reduce infection risks. The provider’s infection prevention and control policy was current and reflected national guidance.

People received their medicines safely and as prescribed. A relative told us, “No issues with medicines that I am aware of.”

Staff received relevant training and understood the processes to follow to support people with their medicines, including accurate recording of medicines administered. A staff member told us, “First I look at the medicines administration record (MAR) and then take people’s medicines to them and then I administer this based on the MAR and then record on the MAR chart.” Senior staff undertook checks to make sure medicines were administered and managed safely. The deputy manager told us, “We make sure staff are following people’s care plans and everyone has a current profile so staff know when people need to be supported. All the staff have been trained in medicines. And we do the audits and this is done daily.”

The service had made improvements and no longer in breach of regulations. Protocols were now in place for’ ‘when required’ medicines (PRN) which ensured staff had the information they needed about when these should be administered to people. Staff practice in relation to record keeping had improved. There were regular audits of medicines. This included checks of staff’s practice to ensure they remained competent and safe to administer and manage medicines. Medicines stocks, balances and records showed people consistently received the medicines prescribed to them. We found one minor issue with a medicine for one person. The prescribing instructions had not been updated by the dispensing pharmacy to reflect this medicine was not to be given regularly but as a PRN. Risk to the person was mitigated because they had not required this medicine for some time. The deputy manager responded immediately during our visit to address this issue and reduce any potential future risk to the person.