Pennings View

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 78 (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 well-established proactive and positive culture of safety, based on openness and honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Incidents and near misses had been consistently recorded with clear details of what had happened and any information on what people were doing in the lead up to incidents. This helped staff identify any situations which could escalate people’s anxieties. Staff had a pro-active approach to prevent situations escalating which minimised distress for individuals. For example, staff identified signs that 2 people were acting in ways that might signal increased anxieties. Staff stepped in, took action to support the people away from each other which prevented an altercation from happening. This incident had been analysed and the actions shared with all staff so they would know how to de-escalate potential distress.

Incidents were reviewed by management and if needed immediate actions taken to ensure people were safe. The service manager told us they shared learning in staff meetings, through processes such as staff supervision and the use of reflective practice. The service manager told us, “We have learned to reflect and analyse, and ask for help if we don’t know what to do. We de-brief, discuss and do a lot of reflective practice, always asking what we could have done differently.”

The provider had effective systems to share learning from across all their other services. The provider’s quality and senior leadership teams made sure safety alerts were shared with managers to cascade to staff. Regular governance and risk review meetings were held to discuss learning and identify themes and trends. This enabled staff to learn from other services and review better ways of working to keep people safe.

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.

If people needed to go into hospital there was a hospital passport and a portable care plan that could go with them. This made sure people’s needs were shared with relevant medical professionals. The service manager told us where possible staff from the service also went to hospital to support people throughout their stay. This made sure people had a continuity with their care and knew staff supporting them.

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.

Relatives told us people were safe at the service. One relative said, “My [relative] is familiar with the house and the staff, and [relative] is always safe.”

The management team were aware of their responsibility to report all safeguarding concerns to the local authority. They had also notified the Care Quality Commission (CQC) where appropriate and necessary. Staff had safeguarding training as part of their induction and an annual training update was provided. Staff understood their responsibilities to safeguard people and knew how to report any concerns.

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.

Risks to people’s safety were identified and had been assessed. There were detailed risk management plans available for staff to know about safe ways of supporting people. Risk management plans had been reviewed and updated if there were any changes to people’s needs. Staff told us they were involved in reviewing risks and management had asked their views on how to make sure people were supported safely.

Staff had training on supporting people who experienced increased anxieties. The provider had systems to regularly review incidents where physical intervention may be needed, however, there was no restraint taking place at this 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.

Staff completed regular health and safety checks which were also reviewed by management. Any identified improvements were shared with the provider's maintenance team and completed in a timely way. During our site visit we found work was being completed in areas such as emergency lighting and fire doors. The work was planned and staff tried to make sure it had minimal impact on people at the service. Staff told us they had no concerns with the environment at the service.

People had equipment they needed which was regularly serviced. If staff needed training to use the equipment safely this could be provided by an occupational therapist.

The provider made 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.

Staffing numbers were calculated by management dependent on people’s assessed needs. We observed there were enough staff available to respond to people in a timely way. People and staff also confirmed there were enough staff to support people safely. The service had not needed to use any agency staff to fill gaps on rotas.

Staff had an induction when they started work which included training and being able to shadow other more experienced staff. Ongoing staff support was provided through processes such as supervision and staff meetings. Staff spoke positively about training they received and told us they were alerted by the provider when updates were required.

Relatives told us staff provided good care for people. One relative said, “I am delighted with the care. The staff communicate very well and they are a good team.”

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.

Relatives told us, and we observed, the service was clean and well maintained. Staff supported people to keep their own rooms clean whilst promoting people’s independence as much as possible.

Staff had training on infection prevention and control and were assessed for competence in areas such as hand washing. Staff also had training on food hygiene and had a rating of ‘5’ from their last inspection carried out by food safety officers at the local authority. Staff had access to personal protective equipment and we observed it being used safely.

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 had their medicines managed safely by staff who were trained and competent. Medicines were stored safely and there were regular stock checks completed. Where people had ‘as required’ medicines there was good guidance for staff to know when to administer this medicine.

The provider was signed up to STOMP (Stopping the Over Medication of People with learning disabilities). This is a national project to try and reduce the use of psychotropic medicines for people with learning disabilities. Staff regularly reviewed the use of this type of medicines and no longer used it ‘as required’. This success was due to a reduction in incidents of distress for people and staff identifying triggers which could cause anxieties.

Regular medicines reviews were completed and staff carried out weekly medicines audits to identify any areas for improvement. Relatives did not share any concerns about medicines management.