St Jude's House

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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

The service was in breach of legal regulation in relation to deployment of sufficient numbers of staff to ensure they can meet people’s care and treatment needs.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Ongoing discussions about preventative measures for accidents and incidents were discussed in team meetings. Information was shared with staff digitally if they were unable to attend meetings.

The registered manager and staff reported safety events to the police, the local authority and to CQC as required.

The provider 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 provider worked closely with people, their families and health and social care professionals to ensure robust risk assessments were in place prior to people moving into the service. People and their relatives were involved in regular reviews to ensure the continuity of safe and relevant care was being delivered. Staff told us they had time to view people’s records and to get to know people before they began to deliver care and support.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding concerns were raised the local authority, and CQC were notified as required. Staff had attended mandatory safeguarding training sessions annually, and refresher courses were provided in between. Staff told us they would have no issue with raising safeguarding concerns with the registered manager or the external partners if they needed to.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed people’s Personal Emergency Evacuation Plans (PEEPs). The records showed that 3 people living at the service required 1:1 assistance to evacuate the building safely in the case of an emergency. Evacuation records between January 2024 and October 2024 showed 2 or more staff had not been able to evacuate all the people from the service during these drills. Despite this the provider had 1 member of staff on duty during the night. This increased the risk of people being able to be evacuated from the service safely by 1 member of staff, leading to an increased risk of harm in the case of an emergency. The provider told us a manager and a member of staff were on standby in their own homes each night to attend in the event of an emergency.

We found the décor of the service was tired, and in need of redecorating, however it was clean and well maintained. The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. We saw documents to support equipment and facilities in the home were well maintained. Safety certificates were up to date. Essential works required were carried out and documented to ensure the environment was kept safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. We found there was not enough staff on duty during the night to reduce the risk of harm to people in the case of an emergency. Pre-employment checks were not robust, we found not all staff had provided full employment histories. We found some right to work in the UK checks were not complete. We highlighted this to the provider who quickly supplied the missing information.

The provider 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 PPE available for visitors to use near the entrance of the building. The PPE included masks, gloves and hand sanitizers.

Staff had training in Infection, Prevention and Control, Control of Substances Hazardous to Health (CoSHH) and in Health and Safety. One staff member said, “The [service] provide all necessary personal protective equipment to ensure both [mine] and [people’s] safety”. Infection prevention control signage was also displayed throughout the service.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider used an electronic medicines management system which supported the safe management of medicines and reduced the risk or error. Medication Administration Records (MARs) were audited weekly.