Penns Mount Residential 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 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.

The registered manager and provider regularly reviewed events, such as incidents and accidents, to identify themes and trends. They used various ways to feedback to staff about incidents and how to reduce risks. An external professional had delivered post falls training earlier in the year which was described as “informative” by staff.

Staff were aware of how to report incidents and documented any injuries sustained. Care plans were updated to reflect any change in guidance for staff. Where people needed referrals for professional advice following an incident or accident, this had been arranged. One visiting professional said, “From my perspective, it isn’t a care home of concern. Staff have taken on board my recommendations”.

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.

The registered manager and staff team worked with health care professionals and partner agencies to ensure people received the care and treatment they required.For example, staff worked with community nurses, GP’s, podiatrists and the community mental health team to ensure people received safe and appropriate care. Comments from visiting health professionals included, “Staff are very informative and there is good communication” and “I can't find any concerns about their service”.

People’s care needs had been assessed prior to them joining the service and this helped ensure their preferences and care needs could be met safely. People were offered an opportunity to visit the service prior to deciding to move in. The registered manager or other senior staff visited people at home to discuss their needs and the admission process. One relative told us, “They [staff] are all amazing. [Staff] visited us at home to talk about the care and what the service offered. This was really helpful”.

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.

People and their relatives reported they felt the service was safe and they were confident in the care and support provided. Comments included, “I’m happy enough here. I'm safe and I feel well looked after” and “I’m very satisfied here. The staff are all lovely, very kind. I have no complaints”.

Safeguarding concerns were identified and reported appropriately, investigated, and learning was taken forward to improve safety for people. Staff had received safeguarding training and were confident in explaining the actions they would take if they had concerns.

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 that the service was working within the principles of the MCA.

There were clear systems for supporting people who lacked capacity, with appropriate use of mental capacity assessments, best interest decisions and DoLS applications. Records showed regular involvement from families, GPs and external professionals to ensure decisions promoted people’s rights and welfare.

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.

Staff had access to clear information to keep people safe. Risk assessments were completed and addressed a wide range of needs, including the risk of skin damage, falls, and the management of continence needs. These assessments were reviewed, and records confirmed people using the service and, where appropriate, their relatives were involved in the review process.

Records showed guidance and instructions provided by relevant healthcare professionals to reduce health risks had been clearly documented and were followed by staff. One professional told us, “I can't find any concerns about their service”.

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 environment was safely maintained. Environmental and maintenance checks were carried out to ensure any concerns were identified and rectified. For example, regular checks on window restrictors, hot water and fire safety systems were carried out. Equipment, such as hoists, were subject to periodic inspection and servicing to ensure they were safe and fit for purpose.

Plans were in place to guide staff about the action to take in an emergency. Each person had a personal emergency evacuation plan (PEEP) with information about their mobility and support needs.

Feedback from relatives indicated that while most areas were of a good standard, some parts of the service appeared'tired'and required updating.The provider demonstrated a commitment tocontinuous improvement, with recent refurbishments including the redecoration of communal areas and the installation of new flooring. A clearenvironmental improvement planwas in place to ensure the ongoing upgrading of the premises.

The provider took action to make 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.

Staff completed training and supervision relevant to their role. Staff said they were well supported in their roles. Comments included, “I had induction when I first started and feel confident to work unsupervised” and “We work well as a team and love coming here”.

Prospective staff went through a series of background checksto ensure they were suitable to work with vulnerable people.

There were mixed responses from people and relatives about staffing levels. People praised the staff team and many relatives reported seeing the same staff regularly, helping to build trust and familiarity. Staff were described as kind, responsive, and professional. However, some relatives and 2 people living at the service said staffing was an area for improvement. They said they would like to see a reduction in call bell wait times and for more staff time for social interaction with people. One person said, “Staff are very busy, but they never rush me”.

During our observation period in the sitting room, there was a lack of staff supervision and support which affected the ability to provide timely support to people reduced opportunities to support peoples’ individual needs, promote meaningful interaction, and identify or mitigate potential risks in a timely manner. During these times, people were observed disengaged, sleeping, or without social interaction or activity.

The provider implemented immediate staffing increases during identified busy periods 7 days a week, and began recruitment activity, with interim measures in place to ensure continuity of support. By the second day of our visit, non-care staff were deployed to support peak times and improve visibility in communal areas; the aim was for non-care staff to identify and escalate people’s needs quickly to care staff.

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 premises were clean and odour free throughout. Relatives and health professionals reported it was always like this. Cleaning schedules were followed to help ensure all areas of the service were cleaned regularly, including deep cleans. Staff had access to personal protective equipment such as aprons and gloves to wear when providing personal care.

The laundry was small but clean and well organised. Laundry was separated into coloured bags to mitigate the risk of cross infection. The temperature within the laundry room was high, making for an unpleasant working environment at times. The provider was aware and was exploring ways of increasing ventilation.

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 received their medicines safely as prescribed for them. Staff were knowledgeable about people and their medicines, and people’s preferences were taken into account.

When medicines were prescribed to be taken ‘when required’ there was personalised information in place to guide staff when these might be needed. However, there were 2 people’s protocols that needed updating after changes to their medicines.

Risk assessments were in place for high-risk medicines such as anticoagulants. However, they were not in place for all people using flammable paraffin-containing preparations. The manager told us these would be put in place and people’s care plans updated with this information.

There were suitable arrangements for ordering, storage and disposal, including for medicines needing cold storage and those requiring extra security. Suitable temperature monitoring was carried out to make sure medicines were safe and effective.

Staff had training and competency checks to make sure they gave medicines safely. Regular medicines audits took place, and we saw that these identified areas and actions for improvement