Pendlebury Court 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

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 remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice

Since the last inspection, the provider had taken action to address some concerns, and we saw evidence that learning took place following accidents and incidents. However, not all areas requiring improvement had been fully addressed. We identified ongoing concerns relating to medicines management, governance systems, and ensuring care plans were regularly reviewed and kept up to date.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. The provider worked with people and healthcare partners to establish and maintain systems of care intended to support people's safety. However, these systems were not always effectively managed or monitored. We identified gaps in personal care and oral hygiene records, meaning it was not always possible to demonstrate that people had consistently received the care and support they required. This increased the risk that changes in people's needs may not be identified promptly and that care was not always delivered in line with their assessed needs.

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. Staff had received safeguarding training and demonstrated an understanding of their responsibilities to recognise, respond to, and report concerns about potential abuse. Effective systems were in place to ensure safeguarding incidents were investigated in a timely manner and reported to the relevant agencies where required. Relatives spoke positively about the safety of the service. One relative told us, “Mum is always comfortable and never in any distress” and another relative said, “The home feels free from discrimination, abuse and harassment.”

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 found inconsistencies within some care records, meaning staff did not always have access to clear and up to date information about how risks should be managed. One person's care plan had not been updated to reflect the most recent guidance from an external professional involved in their care, and several people did not have care plans in place to support certain aspects of their care. These omissions increased the risk of people receiving care that was not in line with their assessed needs or current professional advice, placing them at risk of avoidable harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had systems in place to ensure the environment was regularly checked for potential hazards. We reviewed the health and safety arrangements within the service and found these were subject to regular and effective monitoring. Relevant safety and compliance certificates were in place and up to date.

Relatives told us they felt the environment was safe. One relative said, “Equipment appears safe, mum has an alarm by the side of her bed.” Another relative told us, “The home is clean, tidy and safe.”

The provider did not always ensure staff were deployed effectively to meet people’s needs. The provider had systems in place to assess and monitor staffing levels and evidenced how staffing was reviewed in line with people’s needs and occupancy levels. Staff shared mixed views regarding staffing levels. While some staff felt there were enough staff to meet people’s needs, others described occasions when staffing could be challenging. During our inspection, sufficient staff were present, however, staff were not always coordinated effectively to recognise and respond to people’s needs. We observed occasions where people's needs were not promptly identified by staff. For example, one person required assistance with their drink, and another instance when a person had fallen asleep in a dining chair and appeared to require support to maintain their comfort and wellbeing. Staff only responded after inspectors alerted them to these needs. This increased the risk that people’s wellbeing and support needs may not be identified and responded to in a timely manner.

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 provider had effective systems and processes to monitor infection prevention and control. Regular audits were completed, staff had received training, and we observed staff following infection prevention and control procedures. The service was visibly clean, and measures were in place to reduce the risk of the spread of infection.

Records used to monitor the medicines fridge and medicine room temperatures had not been consistently maintained, meaning the provider could not be assured medicines were being stored within the appropriate temperature ranges. This increased the risk of medicines not being stored safely and remaining effective for use. Staff had also not consistently followed the provider's system for recording the site of application of transdermal patches, which increased the risk of administration errors and meant the provider could not be assured medicines were always being managed safely. However, stock levels corresponded with the records in place, indicating people had received their medicines as prescribed. We also found improvements had been made to the management of ‘as required’ medicines, with protocols now containing person centred guidance to support staff in administering these medicines appropriately.