St Annes Residential Care Home

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 of this key question we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

There was a lack of oversight of concerns, accidents and incidents which meant people continued to be at risk of harm. People and their relatives had told us of their concerns. Care plans were not up to date and were sometimes contradictory; people were at risk of inappropriate care. Staff did not always have training appropriate for their role. The service was not always clean and there was no oversight of the cleaning rotas. Staff responsible for the monitoring of food safety did not report unsafe fridge temperatures to the registered manager because they lacked guidance on fridge safety.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, premises and equipment, and fit and proper persons employed.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives shared concerns with us in relation to accidents and incidents and the lack of action taken following incidents. For example, one person had a fall and sustained no injury, however there was no review of the care plan, and they had a second fall which resulted in a broken hip within twenty-four hours of the first fall.

Accidents and incidents were not appropriately investigated. There was no evidence of actions taken to reduce the risks of reoccurrence. The registered manager had no oversight of accidents and incidents that had occurred. Staff told us they had raised safety concerns with the registered manager, but these were not addressed .

Processes were not in place to monitor accidents and incidents affecting people’s safety. There were no actions taken to ensure lessons were learnt and no evidence of changes to staff practices to keep people safe. People were not reassessed following incidents and care plans were not updated following changes in people’s physical health. There were no clear guidelines for staff to follow to prevent reoccurrence.

People did not have good outcomes. Some people had multiple falls or were at risk of choking as the registered manager had not updated care plans or ensured staff had clear guidance to support people .

Relatives shared concerns with us in relation to supporting people to attend outpatient appointments. One relative told us a person, “has to go to appointments on their own,” and “[They] hate travelling on their own and this stresses [them] out.” This was discussed with the registered manager who told us, “Everyone is now accompanied [by staff] if the family can’t do it .”

The registered manager told us they were unsure who’s responsibility it was to transport people to outpatient appointments . They said, “People’s contract says what is included in their fees. It says whether transport to outpatient appointments is included.” However, they also said they did not know what was included in the contract they had with the local authority as they, “had not seen it,” and they, “don’t know what it says.”

The local authority told us they were acting on concerns raised about safety at the service. They said they found the registered manager was unaware of the need to audit the service to learn and improve safety . The local authority told us the registered manager was reluctant to accept their help.

The registered manager had no oversight regarding the involvement of the wider multidisciplinary team in meeting people’s needs. Referrals to the speech and language therapists were delayed because the registered manager did not act on these with any urgency. There was no evidence of ongoing safety monitoring at the service, the registered manager was unable to explain how people were kept safe. The service relied on prewritten policies from an outside company, but these were not always followed.

The registered manager did not ensure there were accurate records of referrals to other healthcare professionals, for example speech and language therapists and the falls prevention teams. Therefore, it was not possible to ascertain whether people’s needs were suitably met. Systems were not in place to ensure good transition of care. For example, there was no process for conducting pre-admission assessments for people being re-admitted following a stay in hospital. People were not supported when moving between locations. People’s care could be delayed. The registered manager told us for example that once they knew a person was leaving the service they no longer saw referrals as essential and left them for the new service to manage.

People were not safe. A relative told us they had raised safeguarding concerns with the local authority as they did not think the registered manager of the service took their concerns seriously.

Our last assessment was prompted in part due to concerns received about neglect by staff. CQC had received anonymous complaints about care at the service, staff had complained directly to CQC. Some staff told us they had raised concerns with the registered manager regarding the culture at the service and the behaviour of some staff.

At our previous assessment the issues with the staff team and the effect this was having on the culture at the service was discussed with the registered manager who told us they had "an open-door policy" and "no one has raised anything with me." The registered manager told us they couldn't "make the staff like each other."

Following the last assessment, we received assurances from the registered manager and the provider in the form of an action plan.

At this assessment staff told us they had continued to raise concerns of specific abusive behaviour they had witnessed with the registered manager and had also discussed their concerns with a senior staff member. They told us no action had been taken.

We discussed this with the registered manager who denied having received any concerns. We spoke to the provider after the visit and they immediately started an investigation into the concerns.

Whilst we did not see any abuse while at the service, we could not be assured people were protected based on the risks identified during this inspection and the registered manager’s failure to recognise and report risks to people.

Safeguardings were not always raised when they needed to be and safety events were not notified to CQC as required. For example, after a person suffered a burn, although this was recorded in the care notes, including a reference to contacting the emergency services, it was not notified to CQC. People were at risk of harm because the registered manager had not taken any action to safeguard people and did not demonstrate an appropriate knowledge legislation including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3), relevant best practice and guidance .

The registered manager had not taken any action to safeguard people and did not demonstrate an appropriate knowledge legislation including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3), relevant best practice and guidance.

The registered manager had not implemented, robust procedures and process that made sure people were protected. They did not have oversight of safeguarding concerns. The registered manager had not ensured staff received safeguarding training that is relevant, and at a suitable level for their role. Staff were not aware of their responsibilities to prevent, identify and report abuse, including referral to the local authority.

The ambulance service had raised a safeguarding after they were called by a family member to assess a person after they fell. The staff at St Annes had not thought an ambulance necessary at the time, although the person was later found to have dislocated their shoulder.

People were not included in the mitigation of risk. Prior to this assessment we received information of concern from relatives regarding the service’s management of people at risk of choking and falls. We received information regarding injuries people had received as results of falls.

A person who had been admitted to St Anne's with poor eyesight was assessed as at risk of falls. They did not have an associated plan of care for staff to follow in order to manage their risk of falls, or any risks associated with their poor vision. Staff did not have instructions to manage these risks. People remained at risk of harm, because their risks were not managed, and people were not included in how their risks were managed. A person told us they were told to use a wheelchair if they wanted to go into the garden despite their ability and desire to walk.

The registered manager had no oversight of people’s care plans.

The registered manager had not ensured that people at risk of choking had been adequately assessed by a speech and language therapist (SaLT). We discussed the care of a person with swallowing problems with the registered manager who told us, “I think there was a SaLT assessment in hospital, but I’ve not seen it. I got a referral form about two weeks ago but have not completed it because [person] is going to another home.”

There was little evidence that people were involved in the risk assessments in their care. We saw people’s care records contained contradictory information regarding their mobility and risk of falls. For example, one person’s records stated they were fully mobile, had poor mobility, used a wheelchair, used a zimmer frame, needed help in and out of the chair and was unable to standing without staff using a stand aid. Their care plan also described the person as ‘a little less able at the moment’ with no clear baseline of mobility for comparison. Staff were not provided with accurate information or clear guidelines to manage people’s risk of falls .

A new electronic care records system was in use. Not all staff understood how to use it and there were no clear policies in place to show staff what to add to the system, and in what time frame. Records were not updated following any schedule and people were not always included in the updates. This meant care plans often lacked current information.

The service was not always clean and people told us this. One person showed us where the carpet in their room had not been vacuumed for some time, and a rubbish bin had not been emptied.

A staff member told us, “Majority of the home is safe. However, there’s been a leak in the dining room for months, taps are broken in the pantry, communal wheelchairs are in poor condition. Whenever something breaks or needs fixing, I feel like it takes a long time before anything is done about it. If anything gets done about it.”

We found issues with the security of the building. On arrival at the service the door was open, and we were able to enter and tour the building initially unnoticed and then unchallenged by staff. The lack of security placed people assessed as not having capacity to consent to their placement at St Annes at risk of leaving the service without support. The lack of security did not make sure people were safe whilst receiving care.

The kitchenette in the downstairs corridor was poorly maintained. There was no evidence that electrical equipment with the potential to cause injury was maintained in a safe condition.

The registered manager was not able to confirm that electrical equipment with the potential to cause injury was maintained in a safe condition. For example, portable appliance testing (PAT) had not been carried out on some electrical items, including a kettle. The registered manager was unaware of this and did not have oversight regarding the health and safety of the equipment and premises. There was a lack of audit to show that appliances had been checked as safe.

There had not been a practical fire drill at the service. Staff told us they had no practical training in how to assist people down from the first floor. Staff were not trained in the use of evacuation equipment. Staff said they were unsure what to do in the event of a fire. Not all staff were confident in the procedures for emergencies. A staff member told us, “We have never had a fire practice at night and no, I would have to say it would be guesswork to whom walks out of the building at night if anything happens .”

People told us they had to wait a long time for care. For example, a person with poor vision told us, “I have to fumble around by myself to get ready otherwise I might have to wait until 10am to get helped by staff.” Our observations supported what people told us .

At our previous assessment we found that the registered manager did not ensure staff had the skills, knowledge and experience to deliver effective care and support.

At this assessment we found there was some improvement in training, however the registered manager continued to have no oversight regarding staff training and there was no evidence competency checks were completed to monitor staff knowledge and practice.

We found both the registered manager, and a senior staff member had gaps in their knowledge. Specifically in relation to safeguarding and dealing with concerns raised by staff. The registered manager did not demonstrate an appropriate knowledge legislation including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3), relevant best practice and guidance. They did not understand the consequences of failing to take action on set requirements.

This was discussed with the provider who told us, “The [senior staff member] has been offered training in management but has declined it.”

We saw that there was a delay in staff responding to people’s call bells. For example, one call bell rang for 18.5 minutes before it was acknowledged by staff. There were not enough staff to respond to people’s needs .

We saw that the registered manager had not followed safe recruitment procedures. Specifically, the registered manager was not able to evidence staff had been interviewed prior to their recruitment. Staff had not provided a full employment history, there was no explanation regarding a staff member having had multiple short-term jobs and staff’s reasons for leaving previous employment had not been explored. Staff had not had their identity validated with photographic ID and criminal records checks were historic, for example one staff members check was 12 years old. The registered manager had no oversight regarding staff recruitment .

A person told us their room was dirty and the carpet needed to be vacuumed and the rubbish bin emptied. They showed us the dirty carpet. The registered manager explained this by saying the person did not want the room cleaned. However the person and their relative said they did want areas of the room cleaned, although there were delicate items they preferred to clean themselves.

Most relatives told us they thought the service was clean, however our evidence showed there were areas of the service that were not clean.

We discussed the monitoring of fridges and freezers, including those belonging to people who lived at the service, with the registered manager who told us, it was, “not their responsibility as it is not our fridge or freezer.” They then said, “Well just add it to our list of things to do.” They did not acknowledge the importance of food hygiene for vulnerable people.

We saw that some areas of the service were not clean and tidy. The kitchenette in the downstairs corridor was poorly maintained. The kitchenette contained a fridge and a freezer specifically for one person to keep their food in. We saw that they had not been cleaned, defrosted or had temperature safety checks.

The kitchenette contained a fridge for general use. We saw that the fridge was showing an internal temperature of 18C. This was discussed with the registered manager. They told us they relied on staff to tell her if the temperature was outside of acceptable limits and, “I have the records to look at.” There was no guidance for staff regarding the expected temperature range and no instructions for staff to follow if the temperature was outside of normal limits.

The registered manager was not aware of the increased fridge temperature and had no oversight of food safety within the service.

We saw other areas of the service were not clean and well maintained, including bathrooms. This was discussed with the registered manager who was unaware of the areas in need of attention. They did not have any oversight regarding the cleanliness of the environment. No infection control audits had been completed.

There were no risk assessments in place where people were managing their own food storage.

The food hygiene rating for the service, awarded by the Food Standards Agency, was 3.

People told us their medicines were not always administered on time or at all. A person said “they ran out of my tablets, I thought when they got down to the last few they would reorder but they haven’t so I’m waiting”. Their medicines had been missed for three days. A senior staff member was aware but had not acted on this urgently, The medicines arrived on the last day of our assessment but were not unpacked or administered.

Time sensitive medicines such as those for Parkinson’s were not always given at the times prescribed leaving people at a risk of increased Parkinson’s symptoms. Medicines were not managed safely. Medicines were stored in various places such as people’s rooms, a medicine trolley and a cupboard in a staff office. We saw that some of the stored medicines in the trolley were out of date.

Staff administering medicines were distracted and the medicine rounds could take several hours meaning people were not getting medicines at the time they were recorded. We saw that the staff member giving people their medicines was frequently completing other tasks including answering the telephone. Staff told us the medicines round started following the morning handover at 07.45 and was usually finished by 10.00. We saw that all medicines given during this time were recorded as being given at 08.00 irrespective of their actual administration time. There was a risk that as medicines such as paracetamol could be given with an inappropriate time interval.

The registered manager did not have oversight of the medication practices at the service. No meaningful medication audits had been completed so no lessons could be learned or care improved .

A senior staff member told us they were responsible for the medicines at the service. A senior staff member said they had not taken any action when people refused medicines. One person had been refusing prescribed medication for three and a half weeks. This had not been addressed. No one had informed the persons GP, discussed it with the pharmacist or the registered manager. No one had explored the persons reason for refusing the medication.

Ordering systems were not effective, and stocks were not safely managed and recorded. Medication administration records (MARs) showed that time specific medicines, such as those for Parkinson’s, were not given at the prescribed times but were given at the usual medicine round times. The registered manager had not sought advice on medicines management. For example, the local pharmacy had not visited the service to carry out a medicines review. A senior staff member told us the previous pharmacy supplier had visited but this one had not.

Guidance to support staff on the application of topical medicines (creams) was not always in place and records were not accurately made when creams were applied. Care plans to support staff to safely administer when required (PRN) and variable dose medicines was not always accurate and sometimes not available.

A lack of meaningful audit meant that missed medicines, or medicines not recorded were not noticed by senior staff and the issues were not addressed.