Penbownder 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 requires improvement.

At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

People were protected from abuse and staff had the skills necessary to meet their needs. Risks associated with people’s support needs had been mitigated and there were systems to ensure safe transfers of care.

However, the environment was not always safe, infection control risks were not constantly mitigated and opportunities for learning had been missed.

These issues contributed to a breach of the regulations in relation to governance detailed further in the well led section of the report.

This service scored 66 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

When areas for improvement had been identified action was not always taken to address the issues. For example, following an incident when one person left the service without support, action to identify and mitigate risks to others had not been taken.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

The service had systems to ensure people’s needs were recognised and understood in the event that a hospital admission was necessary. In addition, the service engaged positively with other providers to ensure people’s needs were understood prior to any proposed transfers of care.

The provider worked with people and healthcare partners to understand what being safe meant to individuals 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. There were systems to protect people from risk of financial abuse.

People told us they felt safe and a relatives said, “I am happy that [My relative] is safe” and “the staff are wonderful and very mindful of safety”.

Staff understood their role in protecting people from abuse and how to raise concerns outside the organisation should that become necessary. Staff were confident any safety concern they reported would be acted upon by management. One staff member said, “all the information is in the office if we needed it, the processes are there that tells you about who to go to. I have in the past had concerns about people but the staff in our office dealt with everything correctly. They listen to you, they don’t just pretend”.

Managers and staff had a good understanding of the requirements of the Mental Capacity Act (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Restrictive practices had been recognised and necessary applications made to the local authority for authorisation. When additional restrictions were introduced to ensure people’s safety this information was shared promptly with the authorising authority.

People’s capacity to make specific decisions had been assessed. However, it was not clear from the records available that people had been involved, as fully as possible, in best interest decision making.

There were systems to protect people from financial abuse. All purchases made on individual’s behalf were documented and the financial records balanced.

The provider worked with people to understand and manage risks holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had been completed, and staff were provided with guidance on how to protect people from identified risks. Records showed people were regularly repositioned when required and pressure relieving equipment was used appropriately. Walking aids were available, and staff supported people to mobilise safely.

Where people were known to become upset or anxious staff had been given clear guidance on how to offer support and reassurance. The registered manager and staff confirmed restraint was not used in the service. When people refused necessary support staff varied how support was offered to ensure people’s safety. Staff said, “usually, we are giving showers when they want but we ask in the morning and sometimes people refuse so we then monitor that and then approach them at different times or when they are feeling in a better mood.” Prompt referrals had been made for additional support when people’s actions adversely impacted on others well-being. The service had acted on any advice and support provided.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

This assessment was in part completed in response to an incident when a person had left the service without support via a ground floor window on which the restrictor had failed. The person was not injured during this incident but was exposed to significant risk.

Following the incident repairs were made to the specific window restrictor but a wider survey of windows had not been completed to identify any similar areas of risk. During the assessment an additional unrestricted window was identified and following feedback action was taken to mitigate this risk.

Cleaning materials were not always stored appropriately when not in use. In the older persons service, we found a bottle of surface cleaner had been left unattended in an area of the service people could access independently.

The service was well maintained and equipment had been regularly tested and serviced to ensure it was safe for use. Fire drills had been completed, and personal emergency evacuation plans developed detailing the support each person would require in an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People said staff responded promptly to their needs and told us, “the staff are fine”, “there is always somebody around here” and “they come if I need them but I’m normally ok”. A relative said, “I think there are enough” and “there seem to be enough staff, sometimes residents are alone in the dayroom if a carer has taken someone to the toilet but then someone else comes quickly.”

The service was safely staffed and rotas demonstrated planned staffing levels were achieved. Staff said, “in my team and from my perspective the staffing numbers are perfect as we have 3 down here and 2 upstairs and if we are short the deputy manager comes in and helps”. The registered manager told us, “we are fully staffed, we have one new recruit starting next week”. Records showed agency staff were used infrequently to cover periods of annual leave or unexpected staff absences.

The provider ensured staff had the skills to meet people’s needs. Staff completed a formal induction process when they joined the service and their training was regularly refreshed and updated. Staff comments included, “we will be having e-learning every month and every year we have fresh courses”. Every month we have a supervision and every 6 months we have a performance review and then an annual appraisal”.” For the first 2 days I came to the office for the online training and then went home and finished the rest of the online training and then had 3 days induction when I was not allowed to do anything but following the senior”.

The service’s recruitment practices were safe. Necessary pre-employment checks were completed to ensure staff were suitable for employment in the care sector.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Bins throughout the service were uncovered and towels were stored on open shelves in one of the service’s bathrooms. Some staff uniforms in the older person’s service were heavily stained and dirty.

The service had appropriate stocks of personal protective equipment and hand wash facilities were available to staff throughout the service. Staff said, “we have the personal protective equipment we need. So all the gloves, aprons and masks and we have 2 cleaning staff.”

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

People told us they received their medicines when they were supposed to. In the mental health unit there were appropriate arrangements to ensure people took medicines as prescribed. Topical creams were dated on opening and their use fully documented.

Staff were confident they had the skills to support people safely with medicines. Medication training had been provided and staff said, “[The managers] do my medication competencies and will check on me and that goes hand in hand with my supervision every 3 months”.

Medicines were stored appropriately and staff were provided with appropriate guidance on how and when ‘as required’ medicines should be given.

The service had engaged positively with health professionals to reduce, where possible, the use of psychotropic medications. The giving of some medications covertly had been authorised by GP’s. However, the provider had not sought guidance from a pharmacist, as detailed in their policies, on how specific medicines should be prepared to be given covertly.