Pendene 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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Safety incidents were appropriately investigated and reported. Staff knew what to do in the event of an accident or incident. They knew about identified high risks such as if people were at risk of falling. They knew about risk management plans and made sure these were followed.

Accident and incidents were monitored and analysed for trends and patterns so that lessons could be learned and action taken to reduce further risk.

Changes were made accordingly and people’s care plans and risk assessments were updated and communicated to staff during staff handovers.

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.

People had their needs assessed before moving to the service. During our assessment, a person had recently moved in, and staff were in the process of assessing their needs with the person and their family member.

The service had recently been assessed by the local authority commissioning and contracts team. They were assessed as compliant against the standards with some minor improvement actions required. The provider had an action plan to address this.

Important information about each person was recorded on a ‘hospital grab sheet’ to be used when a person accessed other services to support continuity of care and smooth transitions.

Staff referred to external healthcare professionals such as GP’s and occupational therapists appropriately and followed their advice and guidance.

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.

People told us they felt safe. One person said, “I always feel safe. It’s the camaraderie, some of them (staff) make you laugh.” Another said, “They make sure the doors are shut so you can walk about and not feel frightened.”

Staff had received training and described the action they would take if they suspected abuse had taken place or if someone was unsafe. They knew how to identify abuse and how to report it. They were confident any concerns they raised would be taken seriously.

The provider had policies and staff had training to ensure they knew how to protect people from abuse and staff understood their responsibilities.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff understood and followed the principles of the Mental Capacity Act. They knew how to provide care and support in the least restrictive way and in the person’s best interests.

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

People had individual risk assessments and where risk was identified, a plan of care was developed with the person and/or their family member. For example, the risk of developing pressure sores, mobility risks and nutritional risks were assessed. Nationally recognised tools supported staff to calculate risks and to take appropriate action.

A relative told us their family member was safe because staff were constantly monitoring everybody. They told us, “[Family member] has a sensor mat by their bed and chair and they always make sure they mobilise using their zimmer frame.”

Another person had equipment in place to manage their falls risk at night. Further action was taken following consultation, they moved rooms so staff could monitor them better at night through observations and safety checks.

Staff knew how to support a person to avoid them becoming distressed. They used distraction and engaged the person in conversations and activities they were known to enjoy. They understood behaviour should be viewed as communication or could indicate deteriorating health where people may not be able to verbally tell staff. People’s care plans reflected this.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety and fire risk assessments were carried out, and appropriate action was taken where risks were identified. There was raised flooring on entry to the quiet lounge and on one exit to the steps leading to the garden. The provider told us these potential trip hazards were managed through staff supervising people or using an alternative exit into the garden.

There were effective fire safety procedures in place. Staff had received training and attended fire drills, so they knew what to do in the event of an emergency.

The signage, the decoration and other adaptations to the premises helped to meet people’s needs and keep them safe. Routine maintenance and safety checks were conducted to ensure the premises, equipment, and environments remained safe and fit for purpose.

There were systems in place to report any maintained issues. Staff told us any issues were responded to promptly.

The provider told us they had scheduled redecoration for corridors and bedrooms. During our assessment, new garden furniture was purchased to support people to enjoy the gardens.

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 and staff told us there were enough staff to meet their needs. Staffing numbers were calculated according to people’s dependency needs. Staffing rotas showed the required numbers of staff were fulfilled.

Staff said they received the training and support they required. Training records showed a high compliance rate with required training. Managers had good oversight of training completed and systems alerted managers to any training due or about to expire.

Staff were recruited in a safe way. Checks were carried out before employment was offered to make sure as far as possible, only staff with the right skills and experience were employed.

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.

People told us the standard of cleanliness was high. Staff had received training and understood their responsibilities to manage the risks of infection. They were able to describe the correct action to take in the event of a suspected infection outbreak. They had access to personal protective equipment (PPE) such as gloves and aprons.

All areas of the service were visibly clean and fresh. Staff understand the importance of food safety, including hygiene, when preparing or handling food. They followed required standards and practice.

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.

People told us staff managed their medicines in as safe way. On person said, “They come round and give it to you out of the little pots and watch you take them every time.” A relative said, “[Staff] always explain what [family member’s] tablets are and watch them take them.”

Staff responsible for managing medicines had training and had their competency assessed to make sure their practice was safe.

Medicines policies, procedures and systems followed current legislation, professional guidance and relevant best practice to ensure people’s medicines were ordered, administered, recorded, stored and disposed of safely.

Controlled drugs were stored, recorded, administered and disposed of safely. There was effective oversight of their handling in line with current legislation and guidance.

Governance and audit arrangements for the oversight of medicines were in place and effective.