Pentlands Nursing 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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 events were recorded and reviewed through the provider’s electronic care planning program, with actions identified and shared with staff to provide learning and reduce the risk of recurrence. This supported ongoing improvement in practice.

The incident tracker enabled senior staff to have oversight of any incidents such as falls or serious injury. The registered manager said, “Staff know about the incident tracker and if there is a fall the tracker is started anyway. At the end of each incident, there is ‘lessons learned’ and we also have a chat with staff to see if we could do anything better. Every person has a monthly falls risk assessment, unless they have had a fall in which case it could be more often than that.”

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.

Some people had moved to Pentlands Nursing Home from other homes of the provider. This meant information about their care and support needs could be easily transferred over. We received feedback from a healthcare professional who told us, “The home have established effective systems for identifying, escalating and managing residents’ clinical needs. Staff communicate concerns promptly and appropriately, enabling timely clinical review and intervention. Referrals to community services, secondary care and other healthcare professionals are made appropriately, with relevant clinical information shared to support safe decision-making. When residents require transfer to hospital or return to the home, staff make every effort to ensure continuity of care through comprehensive handovers and clear documentation.”

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. Consent had not always been sought with regard to restrictive practices.

We asked people if they felt Pentlands Nursing Home provided a safe setting. One person said they felt safe because there was always staff around and they no longer had to worry about anything. Another person told us, “I feel safe having people around me and nearby. I trust the staff 100% and can call whenever I need them.”

There was no evidence of intended restrictive practices. Some people used ‘attend mobile chairs’ which enabled staff to move them around the home. These chairs had a tilt mechanism so people could relax back into them at an angle with the use of a lap belt; this is a form of restriction and required consent, either from the person affected or in their best interests. The registered manager was unaware this was a restrictive practice or that consent was needed and confirmed they would take action to address this.

Staff completed safeguarding training. The registered manager understood when to report any safeguarding concerns to the local authority and any incidents of abuse or alleged abuse to the Care Quality Commission. They understood people’s rights in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) legislation. Records showed where DoLS had been applied for and whether they had been authorised by the local authority.

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’s risks of unsafe care and treatment were generally managed well. We did, however, observe 1 person had slipped down their bed causing the pressure relieving mattress to move, resulting in a gap at the end of the bed. There was a potential risk of entrapment. The person had moved their pillow to fill the gap and to prevent their legs from becoming stuck. We informed the registered manager about our concerns and received assurances this issue would be fixed.

People’s risks were assessed and managed, with clear guidance set out in care plans that staff followed in practice. One person had recently had 3 falls within a 2-week period; these occurred in the morning when they were cleaning their teeth. Their care plan had been reviewed and updated, with oral care now being completed after breakfast when the person was more awake; this had reduced the falls.

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

Pentlands Nursing Home provided a safe environment for people. We did, however, observe that some window restrictors had been over-ridden by staff, allowing the windows to open wide. This posed minimal risk since people were not independently mobile. We showed the registered manager where windows had been opened beyond a safe limit. They took immediate action and arranged for all windows at the home to be checked to ensure that restrictors had not been over-ridden and were functioning as intended. There was an extreme heat warning in place for the day we visited. Windows had been opened by staff to aid the flow of air and ventilation throughout the building.

We asked people and their relatives what they thought about the environment. A relative said, “The home is well decorated, well maintained, fresh and clean.” People had access to the outside space with ramps for wheelchairs; a lift provided easy access to the first floor. Environmental audits provided ongoing monitoring and checks for the environment, including fire safety, hoisting equipment and utilities.

The provider did not always make sure staff were deployed in a way that ensured people received care and support in a timely way.

Staffing levels were sufficient, but staff were not always deployed to provide care and support in a prompt and timely manner. A dependency tool was completed to identify how many staff were needed to support people safely. We observed staff were not always available to meet people’s needs. We observed care staff were not always readily available in the lounge/dining room which was located down a corridor away from the main part of the home. At one point in the afternoon, the activities co-ordinator was on their own with 8 people; we observed other occasions when this staff member was left unsupported. The activities co-ordinator told us they could ring the bell if they required assistance from care staff or in an emergency. During the afternoon, they did ring the bell, but it took almost 15 minutes for a staff member to attend. The registered manager explained that if there was an emergency, the call bell alarm would sound differently, so staff would know to respond quickly. One person had been sat in the same attend mobility chair for 6 hours from 10.00hrs, and another person from 11.30hrs until 16.00hrs. We were told that people could ask if they needed assistance with their continence, but being left for extended periods put them at risk of pressure damage.

One person told us sometimes they had to wait for staff to respond to their call bell. Another person said, “Nothing is too much trouble. I can use my bell and staff will come.” A relative commented, “Staff do not come as would ideally be liked sometimes, but Mum appreciates that everyone is busy and they do their best, so it isn’t a problem.” A staff member told us, “Some shifts you feel you are on the move, but it’s not anyone’s fault, it depends on the client’s needs. Some days it feels like you need extra staff and I think we could do with more quality time with clients.”

Recruitment systems were effective, and appropriate checks were made to ensure new staff were safe and suitably qualified to work in a care setting. New staff completed an induction programme and a range of training to enable them to undertake their roles and responsibilities effectively. Training was ongoing for all staff, and staff demonstrated their understanding of the training they had received; they had regular supervisions with their line managers.

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.

We asked relatives if they thought the home was clean and well-maintained. One said, “Most definitely! Even the handyman is keen to please. Cleaning and clothes washing is carried out meticulously every day, and the staff who provided this are always pleasant.”

We observed the home was clean and there were no malodours. Staff were equipped with personal protective equipment (PPE) and used this when providing personal care. Staff completed training in infection prevention and control.

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.

We observed a nurse giving people their lunchtime medicines; this was done sensitively and safely. The nurse explained to 1 person what the medicine was for, sat down by their side, placed the tablet in the person’s mouth on a spoon and encouraged them to drink from a beaker. The nurse waited for the person to swallow their medicine safely, then wiped their mouth.

Medicines were ordered, stored, disposed of and managed safely. Nursing staff generally administered medicines to people, received training, and their competency to do so was assessed. The provider had completed effective audits of medicines management.