Penrith Drive

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

We identified 2 breaches of the legal regulations. Effective systems were not always in place to ensure the environment was suitably maintained and infection prevention control procedures were robust. Systems were in place to ensure people were kept safe and protected from the risk of harm and abuse, however improvements were needed to ensure risk management plans were up to date. Staff received support and supervision; however, this was not always in line with the provider’s policy. There were enough competent staff to meet people’s needs safely. People’s mental capacity and ability to consent was taken into account, and people and their representatives were involved in planning their care and support. Staff received training that was relevant to their roles and responsibilities. There was robust recruitment of new staff.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives felt confident to raise any concerns. One person told us, “[staff member] would sort it for me.”

Staff we spoke with understood their responsibility to report accidents and incidents and most confirmed they completed incident forms as required. Staff had regular team meetings where they discussed how to support people who may have complex needs. This enabled the staff to have a consistent approach when supporting people. The registered manager and staff were able to tell us about changes that had taken place in response to learning from a health incident, and how training and knowledge had been enhanced.

We could not be assured that lessons had been learnt by the provider and registered manager. At the previous inspection, concerns were identified relating to the environment. At this inspection, there were still concerns about the environment. It was clear learning had taken place, however, systems and processes in place to identify issues with the environment were not always robust.

People were not able to give us any feedback about safe systems, pathways and transitions.

Staff had an awareness of the risks to people relating to their health and care. Staff made regular referrals to health and social care services and supported people to attend meetings with healthcare professionals. Staff told us there were regular opportunities to discuss changes in people’s care and well-being needs. Information was used to inform people’s care records and pathways to ensure continuity of care.

We did not receive any specific feedback from professionals who worked at the service during this assessment about safe systems, pathways, and transitions.

Systems were in place to enable smooth transitions between services when required. People had health action plans and hospital passports. Some information contained within hospital passports could not be relied upon as being up to date or accurate. Following our feedback the registered manager provided assurances of a review of all hospital passports for accuracy of information.

People’s human rights were not always upheld. Due to people living with complex needs, at times, toilet paper was not always available due to whole roles of toilet paper being put in the toilet. To prevent blockages, on occasions, toilet roll was removed from the bathrooms that this person accessed. This meant other people did not always have access to toilet paper. Other options had been explored, for example, people asking for toilet roll before visiting the toilet, however, the observed this was not always effective. We spoke to the registered manager about our concerns and after our feedback they took immediate action to ensure toilet paper was available and were actively looking for long term solutions.

Staff had not raised any concerns raised about the practice of restricted access to toilet paper.

Staff were able to tell us how they would report any concerns of abuse to appropriate agencies such as local authority safeguarding or the police. Staff told us they knew the whistleblowing procedure and would feel confident raising any concerns.

We saw people were comfortable approaching staff when they needed support. Staff spoke to people in a respectful way, and we observed positive engagement and interactions between staff and people.

Systems and processes in place to protects people’s human rights were not effective. Provider and registered manager audits did not identify the concerns found on the inspection.

Systems and processes in place to identify and report abuse or neglect were in place, and staff had received appropriate training.

The registered manager was responsive to our feedback and was taking action to address the concerns raised.

People were not always supported by robust risk management. For example, a person who was unable to access their bedroom independently if the door was closed, had their bedroom door which was a fire door propped open during the day. This was put in place due to the risk of the person falling while pushing the door open. A request had been submitted to the landlord for a swing free fire door. There were no documented risk assessments in place to manage the risk, although we were assured the door was closed at night. This was addressed during the inspection. Risks to people’s health had been identified, but risk management plans were not always up to date to enable people to receive a consistent approach. This was addressed by the end of the inspection.

People’s relatives that we spoke with told us risk were managed. One relative said, “[Person] keeps their medicines in their bedroom, but the cabinet is locked because they [person] do not understand the risks involved with all their medication.”

There was failure by the registered manager to ensure risk assessments were up to date and available in people’s care plans.

Care staff were aware of the risks to people and knew what measures were in place to mitigate risks. For example, supporting people living with epilepsy. However, there was no clear guidance in place for some risks which could have led to a deterioration in health. After discussing our concerns with the registered manager, risk assessments and guidance was up to date by the end of the inspection.

We observed Staffing working in line with people’s known risks. Staff understood people’s communication including facial and body language cues. Staff were competent in recognising behaviour triggers.

Up to date risk management plans were unable to be found during the inspection. However, these had been located after the site visit. Most risks had been identified and staff knew people well and worked with the person to manage the risks. However, processes were not robust to ensure staff had access to the most up to date risk assessments.

People did not always benefit from an environment that had been maintained appropriately. One person lived with damaged flooring in their bedroom, this had been there since they moved in. A bathroom that was used by a person with epilepsy did not have the hot water pipes protected. The risk had been reduced because the person with epilepsy did not use the bathroom without staff support, however, this had not been addressed in a timely manner. There were also some other environmental issues that required addressing.

The registered manager told us, and was able to evidence the concerns with the environment had been identified and reported to the landlord. There were other areas of the home that required more care and attention by staff to ensure people lived in a welcoming environment. For example, curtains not closing properly eyelets were not appropriately attached the curtain pole and photographs on the walls were not straight.

We observed some restrictive practice in place which had not been identified as restrictive by the registered manager or provider and alternative solutions had not been considered. For example, people’s coats were kept locked away in a cupboard to prevent them being accessed by another person. We spoke with the registered manager about our concerns, and this was addressed by the end of the inspection.

When properties are leased from a landlord and registered to provide accommodation and personal care, it continues to be the provider’s responsibility to ensure the accommodation is appropriately maintained and furnished. The service level agreement in place with the landlord required revisiting by the provider to ensure people did not live in sub-standard accommodation. The registered manager and provider level audits did not continue to escalate the concerns about the environment. Risk management processes were in place for emergency situations including fire safety assessments and individual personal emergency evacuation plans for people (PEEP).

There were enough staff to support people well. People were supported by a consistent team of skilled staff who knew people, their needs, and preferences. Relatives told us staffing ratios were maintained. A relative said, “There are always care staff on shift who know [person] well.” People’s assessed staffing ratios were provided. This enabled people to participate in activities safely and receive consistent and timely approaches to emotional or behavioural needs.

Staff told us there were always enough staff to provide safe care. Care staff or the management team covered gaps in the rota to ensure continuity of care. Staff we spoke with were positive about training available to them. They said, “The training is really good,” and gave them the skills and knowledge needed to support people safely and well. They told us they received a comprehensive induction and training. This included approved training to support people with a learning disability and autistic people.

We observed staffing was in line with people’s needs. Staff understood and interacted with people well. It was clear people felt comfortable with the staff supporting them. We saw positive engagement and interactions between people and staff throughout the assessment.

Staff did not always receive supervision in line with the provider’s policy. Although staff felt supported, supervision was sporadic. Safe employment processes protected people from the recruitment of unsuitable staff. References were obtained and appropriate checks were made to ensure staff were safe to work with people and authorised to work in the UK. The rota reflected safe staffing ratios were consistently maintained. There was a comprehensive programme of training to ensure staff had the skills and knowledge to undertake their role.

People were not always protected from the risk of infection. The kitchen was unclean and unhygienic. Other areas of the home were also unclean.

The registered manager and staff team ensured the kitchen was ‘surface clean’ by wiping down worktops and mopping of the floor. However, there was visible food matter and dirt in the corners of the room, by the taps, on storage and cooking items. Some items of food stored in the fridge and cupboards were past their use by date. We informed the registered manager of our concerns, and the kitchen was deep cleaned during the inspection and new items were purchased. Staff had received training in food hygiene and personal protective equipment (IPC).

In addition to the kitchen area, we observed unclean bathrooms, tiled walls and radiators. We spoke with the registered manager and these issues were addressed during the site visit. We saw staff were able to access aprons and gloves and these were used appropriately throughout our visits. Staff encouraged and assisted people with hand hygiene appropriately.

The audits in place completed by the registered manager and a representative of the provider had not identified the sanitation concerns we observed during the inspection.

People’s medicines were stored and administered safely. People had person centred medicine plans which enabled them to receive their medicines safely and in line with their preferences. Medicine administration records (MAR) were in place to ensure people received their medicines as prescribed. There were systems in place that ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. People had regular medicine reviews to ensure their medicines were current and required.

Staff told us they understood when administered as required (PRN) medication should be given. However, upon discussing with staff some concerns identified during the inspection, they also agreed PRN medicine for 1 person was inconsistent and the guidance was unclear. Staff administered medicines safely. This was supported by training and observed practice competency checks.

Medicines were not always managed safely. Some people were prescribed with medicines to be administered as required (PRN). PRN protocols were not detailed enough for staff to understand in what circumstances this medicine should be administered. It was clear by reviewing daily notes, medication records and monitoring charts there was unclear guidance for staff. This issue had not been identified by medication audits that had been undertaken. We discussed our concerns with the registered manager and the document was updated.