Pencombe Hall

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 improved to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Accidents and incidents were logged, information was gathered about the event, if any injuries had occurred, what actions had been taken and what measures may need to be put into place to reduce further risk. Where needed, staff also carried out post incident checks. The provider had an accident incident matrix which gave an overview of all accidents and incidents which occurred within the service. During our visit the registered manager updated the matrix to add additional sections to enable staff to gather information on patterns and trends. Lessons were learnt to identify and embed good practice. Where areas of concern had been identified with medicines recordings, this had been shared to ensure lessons were learnt in the future.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Pre-admission assessments were completed prior to a person moving into the service to ensure their needs could be met, in some cases people had completed the assessments themselves. People’s care plans demonstrated they were supported to access healthcare services when needed. People had digital hospital packs to share important information should they need to go to hospital in the event of an emergency.

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. People and relatives we spoke with told us they felt safe living at Pencombe Hall. One person told us, “At (age) I feel safe, the doors and gates are locked but that makes me feel safer. It helps me feel confident, I really take these things for granted”. A relative told us, “(Relative) feels safe here and I definitely feel they are safe. At home they were falling daily, they had 2-3 falls here and they’re great with them”. Staff had received training in safeguarding and vulnerable adults and understood how to recognise concerns and what their roles and responsibilities were to ensure people were safe. Staff told us they felt comfortable raising concerns, and these would be listened to and acted upon by the management team. One staff member told us, “I’ve not needed to report a concern here, if did, I would support the person straight away, then report to office –they would listen and act. The office is always open to 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 relating to the service and to individual people were assessed and formed part of a support plan for each person. These included risks associated with the environment, mobility, medicines, skin care and eating and drinking. For people with limited verbal communication and hearing loss, care plans emphasised people’s preferred means of communication to support their understanding and ability to make informed choices by providing information in a way which they understood. We observed people were able to walk around freely in the communal areas.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental checks were carried out by both external contractors and internal trained staff to ensure the service was safe and had regular compliance checks. The sample of rooms we saw during the inspection process, evidenced people’s rooms were personalised and arranged in a way which met their support needs and some rooms had been recently renovated. A relative shared, “The home is always clean, tidy- no trip hazards, things left over, fire escapes not blocked. Always clean and tidy, never smells. Things are well maintained”. The provider had a robust contingency plan in place in the event of an emergency, the registered manager had formed links with the local parish to offer emergency accommodation in the events such as fire, flooding and electrical concerns

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. There were a several staff members who had worked at the service for many years. People, relatives and healthcare professionals commented on how this was beneficial for people, staff had good overall knowledge of people which provided continuity of care. One relative told us, “I’ve seen the same staff over the last 2 years, they know people so well” Another relative said, “It’s the same staff when I call, they know (relative) really well”. Staff were recruited safely and pre-employment checks were carried out to ensure members of staff were safe to work with vulnerable people. These included references and Disclosure and Barring Service checks (DBS). A DBS is a criminal record check to ensure the staff member is of good character to work with people at the service. Staff had received online and face to face training to ensure they had the knowledge and skills to support people safely and effectively. Staff had their competencies checked regularly, some of these included medicines and manual handling.

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 and health professional praised the services infection prevention measures. One relative told us, “Staff wear Personal Protective Equipment (PPE), they are always mindful of viruses, sometimes they will request people wear masks when they visit, they are very careful”. A health care professional described the home as “Light airy and has a nice ambience, its calm, there is no odour here, rooms are clean, bathrooms aways clean, bins emptied, and people are dressed appropriately, people are clean and have fresh clothes”. Staff had received training in infection prevention, and we observed them wearing appropriate personal protective equipment. The service had a policy and procedures in place for Infection Prevention and Control, and regular audits were completed by staff.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, whilst there was no impact to people, we identified not all medicines had open dates on them, and some ‘as and when required’ protocols did not always highlight what actions could be taken before medicines were administered. During our onsite visits, we observed staff offering people consistent, specific support when they became anxious or confused, but the information was not always detailed in peoples care plans. Medicines Administration Charts (MAR) charts were not always completed when ‘as and when required’ medicines were given, therefore, making it more difficult to identify any themes or trends in why additional medicines may need to be administered. We shared this with the registered manager and leaders of the service, who took immediate action and provided us with evidence this had been implemented and would be part of their management oversight processes. We saw where ’as and when’ medicines had been administered, a reason had been documented. People and relatives did not raise any concerns in relation to how medicines were managed. Staff had received training in medicines and had their competency checked.