St Petroc's 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

The service was not safe, and people reported they had experienced and witnessed incidents of abuse. Records demonstrated people had been restrained using unauthorised techniques. Known risks in relation to people’s support needs had not been mitigated and staff lacked the skills to restrain people safely. Staffing levels at night were insufficient to meet people’s needs. Staff did not understand local safeguarding procedures and when they had reported incidents of possible abuse to the registered manager, these concerns had not been documented or investigated. Incidents were not accurately documented and opportunities for learning were missed. People’s wishes and dignity were not constantly respected by staff. The provider did not have systems in place detailing how and when ‘As required’ medications should be used, and infection control best practice was not constantly followed. We identified multiple breaches of the regulations.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The failure to accurately document incidents and accidents that had occurred meant it was not possible for learning to be identified.

Staff reported that some of their colleagues had developed a practice of under recording the severity of incidents that occurred. For example, one staff member described a significant incident when a staff member twice injured a person which was documented as an unexplained injury. Another staff member told us, “[Person’s name] is usually all right, often tried to escape. The other evening [the staff] said they could not do anything with him but overnight [staff] said he was in a lovely mood”. Prior to the inspection the provider and registered manager had not identified that staff were not accurately documenting all incidents that occurred, this meant people had been exposed to ongoing risk of harm.

The provider's systems for identifying significant incidents from daily care records were ineffective. Incidents of unplanned restraint had been recorded in the service's digital recording system. However, the significance of this information had not been identified by the registered manager or the provider quality assurance systems. The service’s accident and incident log only included details of falls that had occurred and identified no instances of restraint. This meant significant opportunities for learning had been missed, and poor or abusive practices had not been challenged promptly. The provider's systems had not ensured people received person centred care. This contributed to a breach of regulation 9 of of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service's assessment process had not been effective and individuals whose care needs were too complex for the skills of the staff team had moved into the service.

Staff and the registered manager had worked with health partners to ensure information about people's needs and preferences was shared when people left the service. However, at the time of the inspection there were ineffective processes to monitor and review the level of people's needs to ensure the service was able to meet those needs.

We did not receive any feedback from partners in relation to transitions.

The service's assessments processes had failed to accurately identify the complexity of some people's support needs. Staff had not been provided with sufficient guidance to enable them to meet the needs of individuals likely to decline support. Following the inspection the provider completed a review of the current care needs of people living in the service and identified that a small number of people’s needs were too complex for the skills of the staff team. The provider advised the local authority of this situation and worked with partners to ensure people’s safety until more appropriate care placements could be identified.

One person described incidents of abusive practices they had witnessed by staff members in the service. This person told us, “There are a couple of staff that I don’t like how they treat one of the residents, [Person’s name] does not like it but [the staff] keep persisting with it to the extent I had a word with them”. A second person told inspectors that they had been roughly handled by a staff member during the site visit. Details of both these concerns were shared with the provider, who took action promptly to ensure people’s safety while these reports were investigated.

Staff did not know how to make safeguarding alerts and contact information for the local authorities safeguarding team was not readily available to staff or displayed in the service. Staff reported concerns to the commission about people’s safety both prior to and during the assessment visit. Staff described specific incidents of abuse, inappropriate care provision and unsafe moving and handling practices to inspectors. Their comments included, “The way some staff are with residents is a bit odd” and “[Staff member’s name is just rough, there is no need to be that rough. A gentle approach to everything is the best approach”. One staff member gave a detailed account of how a person had been injured due to a particular staff members actions. Other staff described the impact on people of incidents when personal care had been provided against their wishes. Staff reported they had raised concerns about specific staff members actions with both the registered manager and the provider’s Human Resources team prior to the assessment. These reports had not been documented or investigated and staff told us they were fearful of retaliation if they continued to raise safety concerns. Following disclosures during the assessment, the commission made safeguarding alerts about the quality of care provided to 7 of the 23 people living in the service and shared details of these allegations with the provider. The provider had failed to safeguard people from abuse. This contributed to a breach of regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During the first day of our assessment, we observed a staff member providing personal care to a person in the ground floor bathroom with the door open. This meant the person’s privacy and dignity were not respected. This example of poor practice was immediately highlighted to the registered manager and subsequently reported to the provider’s directors. This contributed to a breach of regulation 10 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service did not have effective systems to accurately access people’s capacity to make specific decisions in accordance with the requirements of the Mental Capacity Act (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Staff and the registered manager had limited understanding of this legislation and records showed that personal care had been given to an individual with capacity, contrary to their wishes. Where staff and the registered manager claimed to have completed actions in a person’s best interest, these decisions had not been fully documented. Staff had not been given detailed guidance on how and when support should be provided. In addition, best interest decision making records did not demonstrate the actions taken were in the person’s best interest, the least restrictive and proportionate. People’s wishes had not been respected. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had policies in relation to safeguarding and restraint. These indicated that individuals should only be restrained as a last resort and only used in an emergency or when, “the form of restraint or restriction has been agreed as necessary following a risk assessment and has been entered in the service user’s plan of care”. This policy had not been followed by the registered manager or the staff team. Care records showed 3 people had recently been restrained by staff in the service. Two people had been subjected to restrictive practices when personal care was delivered without their consent. Staff involved told us it had been in the person’s best interest to be washed but no records had been maintained of these decisions. No assessment had been completed of the risks associated with restraining people in a bath and care plans did not include guidance on how to provide this support safely. Staff who witnessed these incidents of abuse had reported their concerns to the commission before and during the assessment. One staff member told us, “I saw one person [Person’s name] calling out and shouting when the staff put [Person’s name] in the bath. It was upsetting, [they] were screaming, saying [they] would call the Police and [the person] was frightened and the action was frightening [them]”. Detail of these incidents of unplanned restraint had been documented using the provider’s digital recording system and were available to senior managers to review. The provider's systems had failed to protect people from abuse and improper treatment. This contributed to a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following feedback, the provider took action to ensure people’s safety. Experienced agency staff, skilled in meeting dementia care needs were included on all shifts, disciplinary action was taken and senior leaders visited the service regularly.

Risks to people were not effectively managed or mitigated and this meant people were unnecessarily exposed to risk of harm.

Staff raised concerns about how moving and handling risks were managed at St Petroc’s. They described incidents where staff had used inappropriate and unauthorised techniques to move people without equipment. Staff also reported that it was likely incidents of unexplained bruising were linked to the use of inappropriate drag lifting techniques they described. Staff comments included, “A lot of staff don’t use the equipment, I have complained before but was told I don’t know as much as everyone else” and “I have seen people transferred without proper manual handing, after we all had the training.” The registered manager was aware of concerns in relation to the use of drag lifts and had previously arranged refresher training for staff in safe moving and handling practices. No risk assessments had been completed to identify if any additional controls were necessary to ensure the safety of staff when pregnant. Following feedback, the provider took prompt action to complete these risk assessments.

During both visits we observed one person attempting to leave the service without support. This person had a Deprivation of Liberty Safeguards (DoLS) authorisation in place, however staff had not been provided with guidance on techniques they should use to distract or support this person when they wanted to leave the service.

The service’s systems for identifying, mitigating and managing risks were ineffective and exposed people and staff to unnecessary risk of harm. When incidents occurred, these were not always accurately documented and investigated. This meant opportunities for learning and to improve practice were missed. Risks in relation to people’s dementia care needs had not been identified or managed effectively. A person had entered another person's room at 22:00 on the evening prior to our first site visit and had refused to leave that room until 05:00 the next day. Staff had been unable to closely monitor this situation overnight and had failed to contact management for advice or support. Staff told us this behavior was, “quite normal for [Person’s name]” and described a similar incident that had occurred previously. However, these incidents had not been fully documented, and the person’s care plan did not include relevant risk assessments or guidance for staff on what to do if a person refused to leave another person’s room overnight. Where risks had been identified and care plans developed in response to these risks, records showed planned care had not been consistently provided. For example, daily care records showed a person at risk of developing pressure sores had not been repositioned as planned. The service did not have systems to document incidents when individuals subject DoLS authorisations attempted to leave the service. Details of these incidents had not been shared with the local authority, and care plans did not provide staff with sufficient guidance on how to support or distract people when they attempted to leave the service. The provider did not have systems to ensure risks were recognised and mitigated. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

People told us they were comfortable in the service which was appropriately furnished. The lay out of furniture in both the lounge and conservatory was not conducive to individual conversation as all seats were arranged lining the walls of these rooms. In addition, there was a staff work station in the lounge which was not conducive to a relaxing atmosphere. Changes were made to these seating arrangements by the provider following the site visits.

A director told us, “We do our best to make sure the building is safe”. Records showed prompt repairs had been commissioned following a water leak and upgrades had been recently made to the service’s heating system. However, available moving and handling equipment had not been consistently used to protect people from risk of harm while mobilising.

The service and its equipment was clean and well maintained.

All necessary routine maintenance and safety checks had been completed by appropriately skilled contractors. Although the service did not currently employ a maintenance person that role was being actively recruited with interviews scheduled during the assessment. The provider had taken prompt action to address and resolve fire safety issues.

People and visiting relatives told us that staff responded promptly to people’s needs during the day. Comments received included, “Everyone is very nice here” and “The staff here are very good. They come when I need them ”. We received mixed feedback in relation to staffing levels at night and one person told us, “I would have to say there is not enough at night. There is only 2 of them. Realistically it is not enough with the nature of the residents”.

Staff confirmed that staffing level achieved during our assessments were normal and that the service was well staff during the day. Staff comments included, “Today, staffing is normal. It is only less if someone is sick” and “Everything is well. Today we have 1 senior and 5 carers [on shift]”. Staff expressed concerns about staffing levels at night including, “I think the night ratio of 3 would be better. It is hard when something happened, or someone falls over because both staff have to deal with it. If fire [happened] I am not sure how we would deal with it” and “It was quite busy at night but has calmed down now”. The registered manager told us, “We do need to increase the night staff”.

Rotas showed that the service had enough staff during the day to meet people’s current care needs, but that staffing arrangements at night were insufficient. The service consisted of 3 distinct areas and at night only 2 staff were on duty to support the 23 people living in the service. Eight people required 2 staff to meet their care needs, and this impacted on staff availability and response times while meeting these individual’s needs.

The provider had not used dependency tools to assess the level of staffing required to keep people safe at night. The registered manager had previously identified and reported to the provider in April and June 2024 concerns about staffing levels at night. No action was taken in response to these reports, although the August report noted that changes in people’s dependency levels meant night staff workloads had decreased. The provider’s training matrix showed most staff had completed training identified and necessary by the provider. However, the majority of the training provided was video based with limited opportunities for reflective practice and unable to account for staff individual learning styles. Staff did not have the skills to safely restrain people and training records showed no staff had completed accredited training in safe restrictive practices. Most staff had failed to recognise people in the service were being unlawfully restrained. Although training record showed staff had completed safeguarding training, staff did not understand how to externally report incident of abuse they had witnessed. These failings demonstrated the training provider had failed to relay to staff the skills and knowledge necessary to ensure people’s safety. The provider had failed to ensure sufficient numbers of suitably qualified, competent and skilled staff were available to meet people needs. This was a breach of regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following feedback at the end of the assessment process the provider recognised their staff team were not sufficiently skilled to meet people’s needs. To ensure safety, skilled agency staff had been commissioned to provide additional support to people living in the service. Staff were recruited safely, all necessary pre-employment checks had been completed to ensure staff were suitable for employment in the care sector.

People and visiting relatives had no concern in relation to infection control practice in the service. However, one person commented that their clothes were often misplaced saying, “I see people walking around with my clothes on”. We visited the service’s laundry area and found it well organised with appropriate processes to prevent people’s laundry being mixed up.

The service employed a cleaner and laundry staff member during the week. Domestic staff understood their roles and explained the systems in place to ensure all areas of the home were regularly cleaned. Their comments included, “I have a cleaning schedule that I follow” and “It is a big place for one person, I am in Monday to Friday. The care staff are to do some [cleaning] on the weekends. Sometimes the activities lady comes in [to do cleaning] if I am on holiday”.

The service was clean and appropriate stocks of Personal Protective Equipment (PPE) were available. However, the service was not following best practice in infection control as PPE was not consistently available to staff when required and bins in bathrooms were uncovered and full. At the time of our assessment, one person had an infection. PPE was not immediately available to staff before entering this persons’ room.

Cleaning schedules were in place and all areas of the service had been regularly cleaned. The provider had taken prompt action to manage infection control risks when laundry equipment had recently failed. External laundry contactors had provided support, and necessary repairs had been completed promptly.

People were offered their medication when prescribed and controlled how they took their tablets.

Staff understood the providers systems for managing medication and told us their competency with medications had been assessed.

A digital Medication Administration Record (MAR) system was in use to document the support people had received with the medications. Medications were stored appropriately and securely when not in use. During this assessment, we found the provider did not have robust protocols detailing how and when ‘as required ‘medication should be used. When these medicines were used, records were not maintained detailing why the medicine was needed and its effectiveness. The provider did not have robust procedure in place detailing how ‘As required’ medication should be used. This contributed to a breach of regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.