Pennine 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 good. At this assessment the rating has changed to 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 and the way people's medicines were managed.

This service scored 59 (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 culture of safety. 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. Staff did not always document accidents and incidents appropriately or escalate concerns further to ensure management oversight. While there was a robust governance system to monitor and analyse incidents and learn from mistakes, this process was not always followed. Managers made changes to practice based on feedback from staff, the local authority and ourselves to improve care and then communicated changes and rationale to staff.

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. Information was provided to healthcare professionals to support clinical decision making.

The provider did not always protect all people’s right to live in safety, free from abuse and avoidable harm. The management team were unaware of some incidents that had taken place. This prevented investigations and actions taking place to lessen the risk of reoccurrence and keep people safe. This meant the provider did not always share concerns quickly and appropriately with us. The management team now have new processes in place, so they have greater oversight of all incidents and accidents. The provider had started refresher training for all staff around supporting people who may display distressed behaviours before the assessment started. They had also started reviewing care plans to ensure they were person centred and guided staff on how to provide positive outcomes for people. Relatives said family members were safe living at Pennine View. One relative commented, “No concerns here, [family member] is safe.”

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 and supportive. Care plans did not always contain information to support people who may require additional support to manage their emotions or underlying health conditions. Records indicated 2 people were allergic to specific foods. Both people had meals that contained these foods, neither person were harmed. The provider audited all meal options and their ingredients to mitigate the risk of this happening again. The provider had introduced technology to support staff to manage risk and enhance the lives of people who were significantly vulnerable when moving. The technology had automatic lighting, so illuminates the room if someone gets out of bed. It can detect a fall and alert staff, allowing them to respond immediately. Analysis by the provider has shown the implementation of the technology has led to a significant reduction in 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. We walked around the building and found the building to be clean and tidy. However, the management team acknowledged that some refurbishment and redecoration were need in communal areas and corridors. Regular auditing of the building and required maintenance checks had been done. For example, fire checks and gas certificates were up to date to ensure peoples safety.

Staff felt staffing levels did not reflect the needs of the people being supported. Staff also expressed concerns that staff were shared between floors of the home which made people vulnerable. One staff member told us, “We are not able to give the care they [people] require with these staffing levels. There are times when there are no staff about.” However, another staff member said, “There are enough staff to keep people safe and attend to their needs.” We shared this information with the management team. The registered manager used a dependency tool to assess the needs of people, and the numbers of staff required. We looked at the dependency tool for the time we visited and did not think the tool reflected the time people required based on their current support needs, which may impact on staffing levels. The registered manager told us the tool was completed by management who knew people’s needs very well and was regularly reviewed. Our observations showed call bells were answered promptly, and people were getting the care they needed.

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. Health, safety and infection controls were used to ensure equipment was regularly cleaned, checked and operating correctly, for example wheelchairs and hoists. Staff told us there was a plentiful supply of personal protective equipment (PPE). We confirmed this by looking at supplies the home had. Pennine View had a food hygiene rating of 5. This showed the kitchen’s hygiene standards were very good.

The provider did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. The service did not always make sure that medicines records were completed. There was a delay in starting a new prescribed nutritional supplement, and another where a medicines dose change had not been made on return from hospital. A verbal instruction to temporarily change the dose of a medicine for a third person was also missed. Individual written information about the use of ‘when required’ medicines was not always personalised and sometimes missing. There was evidence of shared learning to improve medicines safety across the group, but the homes audits had not been fully effective in identifying areas for improvement.