St Oggs

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 remained as requires improvement. ​ This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to identify and embed good practice. For example, when reporting and recording incidents and accidents the service had not always recorded enough information to identify or record where lessons could be learnt, and the improvements they had made. However, the service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety investigated and reported safety incidents. Staff and people at the service found the registered manager approachable and would raise any safety concerns. The provider identified national and local learning opportunities and shared this with the service.

The service 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 service worked well with community mental health teams, inpatient mental health teams, and mental health assessment teams to ensure people received treatment when their mental health deteriorated or when people were returning to the service after a period of treatment. The service also supported people to access physical health appointments at the GP surgery or at local hospitals. The service ensured people had all the correct information with them, such as information stored in hospital passports or on their electronic medicines administration records systems (EMARS).

The provider, registered manager and staff had training to understand how to recognise abuse and how to make referrals to the local authority safeguarding team. However, the service did not always recognise when people did not feel safe. For example, some people we spoke with said they did not always feel safe when people returned to the service intoxicated. Additionally, the service had not always recognised when referrals were needed to request a Deprivation of Liberty Safeguard (DoLS) authorisation when a person lacked capacity and required a level of supervision.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe and supportive. Several people living at the service had a dependency on alcohol and would on occasions return to the service intoxicated. The service did not have risk assessments in place to guide staff on what to do when this happened. The provider did not recognise the impact this had on other people living at the service. Staff were reactive when incidents happened, this was due to staff knowing people rather than following any guidance from the provider.

The service did not always detect and control potential risks in the care environment. They did not make sure that facilities and technology supported the delivery of safe care. For example, people who were unable to maintain their own safety unsupervised in the community were able to do so without staff knowledge due to ineffective environmental safety procedures. This placed people at risk of harm.

The service did not always make sure there were enough qualified, skilled and staff. They did not always make sure staff received effective support, supervision and development. At the previous inspection, we identified the registered manager was included in staffing numbers. At this assessment, we found there had been no change and the registered manager remained part of the allocated staffing numbers. This meant when they were carrying out managerial roles, the staffing numbers were reduced to 2 staff. People told us they felt there was not always enough staff, especially if they needed support from a staff member on an individual basis. We reviewed staff training records. Although most staff were compliant with their staff training, 50% of staff had not completed training in Dementia Awareness and Positive Behavioural Support. We found there were good procedures were in place to recruit staff safely.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.  The service had dedicated housekeeping staff who ensured the service was clean and infection control was managed well.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Protocols for 'as and when required' (PRN) medicines did not provide the personalised information needed. For example, where a person required medicines to support them with anxiety or agitation, the protocol did not state what symptoms the person showed when experiencing anxiety or agitation. However, we found medicines were stored safely and staff had completed training and were competent in their role to administer medicines.