Tenby House

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.

The service was in breach of legal regulation in relation to the way people’s medicines were managed.

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 positive culture of safety, where staff were encouraged to report concerns and incidents. Safety events were recorded and reviewed, with actions identified and shared with staff to promote learning and reduce the risk of recurrence. This supported ongoing improvement in practice.

Any incident was recorded with actions; information was shared with staff so learning can take place, and prevent reoccurrence.

The provider worked effectively with people and healthcare partners to ensure continuity of care when people moved between services.

People received co-ordinated, person-centred care, with relevant information consistently shared when they were admitted to hospital or transferred to other settings. Staff often accompanied people to support them during transitions, which helped reduce anxiety and ensured their needs were understood, supporting safe and seamless care.

The provider supported people to stay safe by working in line with safeguarding procedures and ensuring staff understood their responsibilities. 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.

We asked people and their relatives if they felt Tenby House provided a safe setting. One person said, “Yes, I do feel safe. They’re good to us and I don’t have to worry about anything.” A relative told us, “He was in a state when he came here, but he’s much better now and he’s settled. The staff are brilliant.”

Staff completed mandatory safeguarding training. One staff member said, “We need to protect the residents, and we all do the best for them. If they cannot make a decision, we help them in their best interests to provide person-centred care.” 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 when 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.

We asked relatives how any incidents, such as falls, were handled by staff. One relative explained, “She had a fall. She’s got a speaker on the wall that alerts them if she’s hurt herself or anything.” Another relative said, “He’s had a couple of falls, stumbles really. We were notified immediately.”

People’s risks were assessed and managed, with clear guidance set out in care plans that staff followed in practice. We observed staff supporting a person to transfer from their wheelchair to an armchair using a hoist. This was carried out safely, with staff providing reassurance throughout.

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

People felt that support was provided safely by staff, for example, assistance with mobility around the home. One person said, “They don’t like you moving about outdoors. That’s a good thing; you could fall into a bush or something. My relative walks me round. They say it’s all right if you have someone sensible with you.”

A healthcare professional told us they met with a person in their bedroom, a room which was bright, clean and well-maintained, providing a pleasant and comfortable living environment. Signage around the home assisted people to orient with their surroundings. Corridors had handrails and sensor lighting to help people as they walked around, in addition to a lift to the upper floor. Fire doors were installed, and fire safety precautions, including training for staff, were in place. Environmental audits had been completed to ensure safety measures were implemented.

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.

Overall, people felt there were enough staff on duty and that they provided assistance when called. One person said, “At one time there wasn’t, but now they’ve got enough staff.” A relative told us, “Oh yes, you press the button and they come quickly.” A dependency tool was used to calculate how many staff were needed, including when people’s needs changed. The registered manager explained, “When a new resident arrives, we work out how much care they need for each area, supervision, meals, personal care, medication, that’s all included.”

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 role and responsibilities effectively. Staff completed training on learning disability and autism awareness. Staff demonstrated their understanding of the training they had received and 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.

People and their relatives felt the home was clean and commented positively on this aspect. One person said, “Well I’ve always got a clean bed and a clean bathroom and toilet. That’s always clean, always. The hygiene is A1.” A healthcare professional who had visited the home said, “The environment was clean, safe and personalised.” Our observations concurred with these comments; the home was clean, welcoming and there were no malodours.

Staff completed training in infection prevention and control. Personal protective equipment was in use as needed, for example, disposable gloves, aprons and hand sanitisers when staff provided personal care. A staff member told us, “A few months ago there was a ‘flu infection so everyone had to use masks, wash their hands with every task they completed, proper waste disposal, and using antibacterial wipes for beds and rails to prevent the spread of infection.”

The provider did not always make sure that medicines were managed safely.

We observed a staff member giving people their lunchtime medicines. Although the staff member was kind and sensitive to people when giving them their medicines, they failed to sanitise their hands at any point during the time we observed them. This is a potential infection risk.

We found a medicine that was stored securely in a separate cabinet in the medicines room was unlabelled. We were told this was a requirement of the pharmacy as this medicine was due to be returned since it was no longer needed. However, there was no indication of what the medicine was or for whom it had been prescribed for. We asked our medicines team for advice. They contacted the pharmacy who stated that, for this particular medicine, the drug should be placed in a separate bag, labels and packaging should be retained/included, the driver collecting the medicine should be informed, and the medicine should be handed directly to them. However, the home had removed the label from the bottle of this medicine, which meant the medicine could be misused. We have asked the home for copies of their records to show the audit trail for this drug.

We asked people if they received their medicines when required and whether any changes were discussed with them. One person said, “Yes, it’s always on time, I’ll give them that. They’re very strict on that.” A relative said, “Staff ring me up and let me know about any medicine changes.