St Peter's House

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• 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

We assessed a total of 7 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was requires improvement. Our rating for this key question remains requires improvement. During our assessment of this key question, we identified continued breaches of the legal regulations. We found continued concerns around risk management, the safe management of people’s medicines, and learning from concerns, complaints and incidents. Systems and processes were not in place to ensure the safe management of medicines. Where people were prescribed 'as required' or variable dose medicines, clear guidance was not always recorded to help make sure staff administered an appropriate dose of people's medicines when needed. The management team were proactive in responding to our feedback and planned action to improve. This resulted in a repeat breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

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.

People told us they felt safe living at the home and said staff mostly treated them well. One person said, “I cannot fault them [staff], they cannot do enough for you.” One relative said, “My, [person’s relative] has said they are quite happy, the only thing they do not like is when staff speak to each other in their own language and do not translate what they are saying. There are a lot of activities. They are generally happy."

Governance systems were in place which included a review of accidents and incidents, acquired infections. This enabled the provider to carry out analysis of patterns and trends with recorded actions in response. There was a system of daily flash meetings involving heads of departments within the service to aid communication and monitoring of people’s needs. This meant systems were in place to review the quality and safety of care provided. However, the systems in place failed to identify the shortfalls we found at this inspection.

At the last inspection, published August 2023, the provider was in breach of regulations because they failed to ensure appropriate risk management guidance was available for staff and safe staffing in the home. Whilst we noted improvement in the management systems for monitoring and oversight of risk, further improvement was needed. There was a system in place to record and monitor falls and other accidents and incidents within the service. However, the analysis of these tools was not always effective. For example, the accident and incident log recorded accidents and what had occurred, and injuries sustained. There was not always evidence in daily records to show what actions had been taken to mitigate future risks.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people and their relatives said they received safe care. One person said, “I have not felt unsafe at any time I can think of.” And “I would say the staff are on the whole kind and considerate.”

Staff were aware of safeguarding process and said they had received training in how to keep people safe. The registered manager confirmed staff had received regular training in safeguarding and were supported to raise concerns should they have any.

During our visit we observed staff supporting people with dignity and respect. A recent safeguarding incident showed staff were confident to raise concerns related to the mis management of medicines, reporting to the registered manager. Whistleblowing is the term used when someone who works for an employer raises a concern about malpractice, risk (for example about people’s safety), wrongdoing or illegality, which harms, or creates a risk of harm, to people who use the service, colleagues or the wider public. Action had been taken in response in line with local safeguarding protocols to investigate.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service was aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

People told us they did not always have access to necessary equipment, such as hoists and slings to help them transfer safely. One person told us, “They only have one Sara Steady in the whole home. This means I have to wait for staff to finish using it elsewhere before I can go to the bathroom. The manager also wants it cleaned between each use which means you are left waiting.” People also told us they felt safe living at the service. Comments included, “I have no concerns with any of the staff, I feel safe with them.” And “I think I would say this is a safe place to live. There isn't any of the staff I don't feel safe with.”

Staff told us electronic care plans and risk assessments were accessible to them. Staff described how they supported people to do as much as possible for themselves and retain their independence. Comments included, “We ask people what they want and what they can do themselves. This involves being patient and not rushing people.” And “I think it is important we don’t take away people’s independence and allow them to do things which may take longer than how we would do things.” However, care plans did not fully identify risks associated with people’s care and support needs. For example, as highlighted in the processes section of risk management in this report.

We observed insufficient amounts of hoists available at all times to support people when needing staff to support them to the bathroom. In response to our findings the manager ordered additional stand aid equipment. We also requested the manager carry out a comprehensive assessment to ensure the availability and range of equipment needed at all times to meet people’s needs.

Risks associated with people’s care had not always been identified. Risk assessments were not always up to date and clear. This put people at risk as staff did not always have the guidance needed to keep people safe. Care plans did not always contain enough information to support people with their health care needs. For example, where people had been diagnosed with asthma, Parkinson's, dementia and diabetes. Care plans were not always clear as to the interventions needed to support people we observed exhibiting emotional distress. Improvement was needed in the oversight and monitoring of people’s catheter care and bowel monitoring where people were at risk. For example, one person’s care records showed 8 consecutive days without any bowel movement, but their prescribed laxative had only been given once. This increased the risk of bowel impaction. People’s catheters were not always placed on a stand to prevent the risk of cross infection as these were observed to be placed on the floor. Where people required weekly catheter bag changes as described in their care plan, records maintained did not always evidence this had taken place. Management monitoring systems had failed to identify these shortfalls. People’s care plans recognised when they required a catheter; however, detailed guidance had not always been provided about how to care for the catheter. Care record documentation was inconsistent in relation to what signs staff should be aware of, if the person had an infection or the catheter was blocked and what action they should take in response. Where care plans stated weekly bag changes were needed daily notes did not evidence this had always taken place as required. There was a lack of systems in place to monitor how regularly bags were changed. This meant people were at risk of acquiring infections.

Most people and relatives told us the environment was safe. We were told, “There is never any smell, and no one ever looks dirty.” And “I have no concerns. Last year the place was decorated. They got rid of the carpet in the main hall that did smell. The place doesn't smell now and is a lot fresher.”

Managers told us of improvements made to the environment since our last inspection. These areas included redecoration of communal areas and new flooring.

We found the environment people lived in was well maintained. People had access to pleasant, well maintained indoor and outdoor spaces. However, further work was needed to ensure people who used wheelchairs could access garden areas independently of staff as not all doorways had ramps to enable them easy access. Also, additional work was required to ensure an environment which met the needs of people living with dementia.

Records of safety checks that had been carried out on equipment and the premises were maintained, and up to date and available for us to view. We discussed with the registered manager our concerns that the environment needed improvement to meet the needs of people living with dementia, we were told that this had been recognised as an area of improvement needed and a dementia specialist had been sought to provide guidance and advice to make improvements.

At our last inspection we identified a breach of Regulation 18. In August 2023 there were insufficient staff to meet people’s needs in a timely manner. At this inspection, we received mixed feedback from people around staffing levels. Some people told us the staffing levels were not always adequate to meet their needs in a timely manner, however, others provided positive feedback.

Staff told us there were sufficient staff on duty to meet people's needs. They told us they felt supported by the management and were happy with the training they received. The registered manager told us vacant shifts were covered by agency staff as well as permanent staff picking up extra hours. A twilight shift had recently been implemented to support busier times of day.

At our last inspection, the provider had not ensured there was sufficient staff to meet people’s assessed needs. At this assessment we observed there were sufficient staff to support people safely, but further work was needed in relation to the delegation of tasks to staff. Care staff were observed to be very busy and often task orientated. The provider has since taken action to rectify this by providing additional staffing during the busy periods of the day.

The provider had a system in place to determine the number of staff needed to meet the dependency needs of people. The registered manager told us staffing ratios had recently been increased in line with an increase of people living at the service. Staff had completed their on-line mandatory training. Face to face training had been provided to staff from external agencies. For example, dementia care, nutrition and maintaining skin integrity.

People and relatives told us the home was generally clean and well maintained.

The manager told us night staff were responsible for cleaning equipment used to help people mobilise. Governance systems had not identified where bathroom pull cords were dirty and in need of replacement, gaps in staff carrying out regular cleaning of mobility aids such as wheelchairs and hoists. This shortfall had also been highlighted by the provider in their recent mock inspection without action taken.

We observed environmental and infection prevention and control risks which had not been identified by staff and management. For example, we observed wheelchairs and hoists that were dirty and in need of cleaning. Throughout the service light pull cords in bathrooms were uncovered and stained. This meant people were at risk of cross infection. In response to our feedback the provider took immediate action to address this.

There was an infection prevention and control (IPC) policy and process in place. Notices about safe IPC practices were displayed throughout the home, such as hand washing procedures. However, further work was needed to ensure governance systems identified the shortfalls we found at this assessment. Governance systems had not identified where bathroom pull cords were dirty and in need of replacement, gaps in staff carrying out regular cleaning of mobility aids such as wheelchairs and hoists.

Care plans were not always accurate, up to date and reflective of people’s current medicines prescribed. Prior to our assessment we received information of concern where people told us they had not received their medicines as prescribed including pain relief. We observed staff administering medicines to people without their medicines record at the point of administration. Medicines were also being prepared in the medicines room away from the person. This meant there was a risk that the staff administering medicines could get distracted and give the medicines to the wrong person. We observed the storage of medicines on site to ensure they were stored safely and securely. We found the storage of medicines did not follow the provider’s medicines policy with improvements required in the security of medicines. Room and fridge temperatures where medicine was stored were monitored correctly.

Staff interacted with people kindly and provided support to people when medicines were administered.

People did not always receive their medicines on time. We reviewed the records for one person who was prescribed time sensitive medicines for Parkinsons disease. These were often given late, which could result in the worsening of symptoms. The provider used an electronic medicines administration record (eMAR). however, we found there were no topical medicines administration records, and no ‘body maps’ to guide staff for where the creams should be applied. For example, we looked at the guidance available for one person who was prescribed a steroid cream. There was no information to support staff as to where on the body this steroid cream needed to be applied. We reviewed records for one person who had developed a pressure ulcer. Due to the lack of correct documentation, the service could not be assured that the correct cream had been applied according to the prescriber’s instructions. There were no tools available to assess people who were unable to verbally communicate when they were in pain. Staff monitored bowels for people at risk, however they did not always escalate or administer treatment effectively when people were constipated. For example, we found gaps of up to 8 days. Prescribed laxatives were not always administered when needed. This meant there was a risk of harm to people. Recent incidents had been identified whereby 3 senior staff had disposed of medicines in bins instead of administering to people had been identified. This meant people had not received their medicines as prescribed. The management team took appropriate action to investigate this and consult with health professionals. However, no action had been taken to contact the people affected and or their relatives to inform them of this incident and advised of the action they had taken in response to their findings.