Prema Court

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. We identified a breach of regulation in relation to the premises (safety of the environment and infection prevention and control). At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safeguarding, safe care and treatment, the management of people’s prescribed medicines, premises, staff training and development.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. This was evident from the providers previous failures in this area, and the continued failures identified at this assessment.

Records showed a high number of incidents where people had become agitated and become verbally or physically aggressive towards both staff and people living at the service.It was not clear within the records if themes and trends had been explored, and what management plans were put in place to mitigate the risk of these types of incidents recurring. In addition, an action that was identified after a visiting professional banged their head on a low roof on Brook building in December 2024 had not been completed. Staff were aware of the procedure to follow in the event of an accident or incident, however there was no evidence that any learning was being taken from the incidents to prevent their recurrence and keep people safe. Staff meeting minutes did not reflect areas of learning or embed good practice.

One staff member told us they felt staffing levels were not sufficient to support people when relapsing or displaying behaviours that challenge others, at times exposing staff to unnecessary risk.

We also identified some incidents had not been reported to the commission as required by law.

The provider did not always work well with people 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, including when people moved between different services.

Staff told us they had access to information about people’s needs through the care records. We again found there was a lack of support to help people understand their addiction or mental health and there was a lack of clear strategies to effectively guide staff in supporting people to achieve their goals. A review of records had not always been completed ensuring information accurately reflected people’s current and changing needs. This also included the hospital pack, which would be used when people are transferring between services.

Nursing care ceased to be provided at Prema Court from the 1 March 2025. Additional monitoring of people’s healthcare needs had not been maintained following this.

People were attending a local mental health clinic for any appointments and treatment. We noted one person refusing to attend the clinical, alternative arrangements had been attempted but had initially been unsuccessful in ensuring they received the treatment they required. We were told the service had good support from the local GP. Following discussions with the surgery arrangements were made for the GP to hold weekly surgeries at the home, helping to minimise the number of missed appointments.

The provider is now working with partner agencies to address areas of improvement, so people are kept safe. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Effective systems were not in place to ensure people’s rights were upheld and protected. Where necessary, lawful restrictions to deprive people of the liberty had not been sought in a timely manner as outline within the Mental Capacity Act codes of practice. Information to monitor authorisations was not accurate or complete meaning we cannot be sure appropriate action was always taken to ensure people’s safety.

Staff felt able to raise any concerns with the manager and were aware of the procedures to follow in relation to accidents and incidents, safeguarding and DoLS procedures. We found some accidents and incidents had not been referred to us as required by law.

We reviewed a summary of accidents and incidents between January 2025 and March 2025. This identified the number of incidents each month involving people living at the service. . However, there was no further analysis of the information or identified actions in response to mitigate further accidents and incidents from happening.

Policies and procedures were in place in relation to keeping people safe and protecting their rights. However, these were not always reviewed and updated ensuring clear information was available to guide staff in line with good practice and people’s rights were protected. Training records showed staff had completed training in safeguarding, Mental Capacity Act and deprivation of liberty safeguards and duty of candour.

During our assessment we identified concerns in relation to the safe care and treatment of people. These were raised with the local authority.

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.

Areas of risk to people’s health and well-being had been assessed. However, these were not kept under review. Effective management plans and additional monitoring were also needed to ensure staff were able to identify and respond to people’s changing needs. We looked at the care records for 6 people. Additional monitoring of people’s weight had not been undertaken since February 2025. This was concerning as three people were at risk of malnutrition and dehydration and had been losing weight.

Records for one person showed a Malnutrition Universal Screening Tool(MUST) assessment was in place. The person was assessed as high risk, the action required stated ‘treat’. It was unclear from the records what this meant. A water-low risk assessment had also been completed for this person as they were identified at risk of a pressure injury. There was no further information to guide staff on the action required to effectively manage these areas of risk and ensure the safety of the person.

The nutritional risk assessment for another person was rated as high risk. Action identified required staff to consider recording the person’s daily intake, weekly weights and dietary supplements. Information regarding food texture was conflicting, referring to both level 6 and level 7. There was no information to show supplements were offered. A fluid watch assessment had also been completed but was not scored. Information stated the target intake should be 1500ml a day. However, records for the days prior to our visit showed no record of any fluid intake. We were not assured peoples nutrition and hydration needs were being met.

Another person was at risk of falls. Incident reports 9 incidents where the person had fallen between August 2024 and March 2025. We were advised there was not a current risk assessment in place regarding falls management for this person. This meant staff were not guided to safely support the person, helping to mitigate further risks of harm or injury.

Staff told us due to the reduction in staff the monitoring of people was more difficult. Staff felt there were not sufficient numbers of staff to support people when relapsing or displaying behaviours that challenge, and at times they felt exposed to unnecessary risk. We reviewed the staffing arrangements in place. We were aware prior to the assessment that nursing care was no longer being provided at Prema Court. Current occupancy levels were 29. We were told one staff member would be deployed to each of the 3 floors in Clifton House and 2 staff in Brook House. Senior support staff would take responsibility for medication administration. From our observations we found staff provided a level of supervision of people. However, were not able to provide more meaningful opportunities to support people therapeutic needs.

Records showed there were still instances of people bringing alcohol into the service. Additionally, we were told staff were not able to ‘search’ people where they suspected items were being brought into the service. This conflicted with the services alcohol policy, which stated alcohol consumption is not allowed on the premises. However, if there is any evidence or suspicions that people are consuming alcohol on premises, a search may be authorised as per Deepdene`s “Policy for the search of Residents: Person, Rooms and Personal Belongings”. Incident reports showed alcohol had been consumed by people on the premises, which had resulted in incidents of anti-social behaviour. No action had been taken by the provider to address this to mitigate these types of incidents from recurring.

Environmental risks were monitored with regular checks to the premises and equipment. During our assessment a further inspection was undertaken by Greater Manchester Fire and Rescue Service. Action was required by the provider in relation to the fire risk assessment evacuation procedures in the event of an emergency arising.

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

The fire alarm system had been recently serviced; however, we were informed, whilst the alarm sounded along the corridors alerting people to a potential fire, it did not sound in individual bedrooms.

At the last assessment, the provider told us, a new fire alarm system would be fitted, however, this had not occurred. The fire service visited the home in May 2024 and issued enforcement notices telling the provider to improve the fire safety across the service. The provider had not adhered these notices. People were prohibited to smoke in their bedroom, however, smoking continued to occur which placed people at risk. Assessments identified the frequency of monitoring checks to be completed by staff, helping to reduce the risk of fire. We were not satisfied these were carried out as records reviewed provided little evidence of checks being made.

Servicing of mains supplies, fire equipment, call bells and emergency lighting had been carried out in addition to internal checks. Servicing certificates for emergency lighting identified 4 lights had failed the test. There was no further information to show how the provider had addressed these issues. Additional information was provided to show mains electric and gas safety checks had been carried out.

It is acknowledged some work has been carried to improve standards within the service. This includes the repainting and new flooring to the 1st and 2nd floor of Clifton House. However, parts of the service were in a poor state of repair and exposed people to health and safety risks. In one bedroom on the ground floor, the ceiling over a bay window had deteriorated and the plaster had begun to disintegrate. In another room, the ceiling light and bulb was exposed as the cover had been removed and, in some bedrooms, the perspex door plaques were broken which posed a risk to people in terms of injury and being able to self-injury. We reported this to the management team during our visit.

Multiple concerns relating to the safety of the environment were raised at our last assessment. Following our last assessment, we requested regular updates on the progress of required improvements. At this assessment we found the provider had not taking timely action to remedy environmental safety concerns, these were in relation to up grading one of the bathrooms, replacing scorched baths and flooring and addressing garden areas which were again overgrown and littered with cigarette ends. We also found piles of rubbish had been dumped on a 1st floor roof. We were informed this had only been there a few weeks however difficult to reach due to the inclement weather. This was not accepted and removed the following morning.

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.

The provider was not always following safe recruitment processes. Dates of previous employments for some employees did not match the dates on the references given and references were not always verified to ensure they were provided by the correct referee. There was also no confirmation the provider had satisfied themselves the relevant visa checks had been carried out for those agency staff working at the home.

Staff received training to support their job role. However, the majority of training was completed via e-learning and did not check staff knowledge. Less than 50% of staff had received face to face training in behaviours that challenge, basic life support and first aid, some of which had now expired. We found no evidence training had been completed by permanent and agency staff in areas such as de-escalation, addictions and mental health had been provided, which reflect the primary needs of people living at Prema Court. New staff were said to complete an induction to the service, in line with best practice. However, there was little evidence of this on file. This did not reflect standards as outlined by skills for care providing a well-planned, supportive induction which contributes to staff wellbeing.

We reviewed staffing levels and found rotas reflected a consistent number of staff on duty; however, it was not clear if the provider had assessed if enough staff were on duty to meet people’s individual needs. We observed people sat waiting in the dining room for 15 – 20 minutes without any monitoring by staff. Staff were not always visible throughout our visit and one staff member who had transferred their employment from another of the provider’s services could not tell us who was in or away from the service.

We were told staff were allocated to a floor each shift across Clifton and Brook House. Support staff said they spent much of their time cleaning bedrooms, as some people were reluctant to engage in this task. One member of staff said there had been a reduction in staff and felt this had made it more difficult to monitor and effectively support people when relapsing or displaying behaviours that challenge.

A supervision matrix showed supervisions had been completed. A copy of the form was provided. This explored areas such as progress updates, personal issues, safeguarding, health and safety, personal development and teamwork. However, we saw no evidence of recent meetings having taken place. Staff meetings minutes were seen. These showed discussion had included staffing arrangements, job role and recent changes within the service provision.

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

The home was visibly unclean and unhygienic in parts. Communal corridors, stairwells and lounges were stained and dirty with ingrained dust and grime within paintwork, floorings and fixtures and fittings. Several hand gel units were inoperative. Bedrooms were unclean with several rooms having exposed, unclean pipework around washing facilities. Several bedrooms and bathrooms still had scorch marks to the flooring and mattresses, bedding and curtains were stained.

Kitchen area’s which had recently been refurbished were unclean and there was evidence of food debris across the floor.

Infection control audits had been completed in September 2024, they identified some improvements were required to support effective infection, prevention and control. A further audit was completed in March 2025 which found the home to be generally compliant. This audit had not captured the long standing cleanliness issues we found as reported on in this report.

Housekeeping staff worked at the service but there was a wider reliance on care workers to complete cleaning of people’s bedrooms.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Improvements were needed in the management and administration of people’s medicines. Following the removal of the nursing registration, administration of injection medication was now being administered at a local clinic. Senior support staff were responsible for the administration of people’s oral medication. Competency assessments had not been carried out in a timely way to ensure practice was safe as outlined within NICE guidance.

Medicine administration records were not accurately maintained, and gaps were unexplained. Care plans did not fully reflect people’s medication needs particularly in relation to medicines used to manage addiction or required regular monitoring. We also found antibiotic medication had not been administered as prescribed. There was no record to explain why and if this had been investigated and addressed with staff. We were not assured people received their medication as required.

We again found ongoing issues regarding the air conditioning unit. Room temperature readings were higher than the recommended storage requirements for most medicines.