Pennington Court

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.

This service scored 69 (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. There was a learning culture in the care home. Staff were aware of procedures to follow to report and record incidents. We saw that accidents and incidents were reviewed and analysed to identify themes and trends. Feedback to the staff team was provided through team meetings and discussions.

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. We saw evidence in care plans of visits and referrals when required. Staff told us health care professionals regularly visited the service, and information was shared and reviewed to ensure people’s needs were met. Feedback we received from visiting health care professional was very positive. One professional said, “It is a good service, staff respond promptly to peoples’ needs, ask for support and follow specific plans.”

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. Staff understood safeguarding procedures and reported incidents immediately to management.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People's capacity was assessed in line with MCA and decisions were made, where people did not have capacity, in their best interest.

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 which mattered to them. Risks associated with people's care were identified and, predominantly, managed effectively. A health care professionals said, “Staff are supporting people with very complex needs, and they manage this well, following advice and guidance to mitigate risks.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Some areas of the care environment still required improvement and refurbishment, which was being addressed. Appropriate checks of the environment and associated services, including fire, water and equipment, had been completed and were reviewed by the provider. There were only 2 staff on duty at night, although staff told us this was adequate to meet people’s needs, it was not clear if in the case of emergency that 2 staff would be able to manage it safely. The registered manager told us they had carried out a mock fire evacuation with staff on nights and this had met the required timescales, and everyone was evacuated safely. They also assured us that safe staffing levels were continuously under review and were looking at increasing staffing when the new person moved in.

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 which met people’s individual needs. Members of staff were recruited safely and there were sufficient staff to meet people’s care and support needs. Staffing levels were determined by the needs of the people who used the service. There were a number of service users who had commissioned 1 to 1 hours. We found adequate staff were on duty during the day to accommodate these hours. However, it was not clear if the people received their 1 to 1 hours as no allocations were recorded, so it was not always possible to determine if people were able to access the community when they requested. Records were seen of activities received however, no start or finish times were recorded of the activity.

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. The care environment was predominantly clean, and staff has access to appropriate stores of personal protective equipment (PPE). Members of staff had access to infection prevention and control policies and a recent external audit of the care environment noted improvements had been made and sustained. However, we found some areas of the service were not well maintained and unable to be effectively cleaned, these included shower chairs and en-suite facilities. Since our site visit, we have received confirmation from the provider that these either have or are being addressed.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Administration of medications was managed safely. Members of staff had access to policies and procedures which supported safe clinical practice. Staff were knowledgeable on peoples’ medicines and specific requirements. Audits of medication administration were completed and reviewed by the management team. A recent audit by the quality compliance team identified some areas for improvement, these were put into an action plan and were being addressed.