PentaCare (West Suffolk)

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. This is the first assessment for this service. This key question has been rated Good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Systems were in place to learn lessons from incidents, complaints and safeguarding concerns so they could be analysed for patterns and trends. The outcomes were used to prevent reoccurrence and promote safety.

The registered manager was proactive in sharing lessons learnt including good practice to staff to underpin the quality of care provided. The management team were open and transparent about incidents and accidents that occurred, these were recorded and reported appropriately.

Staff were confident in the management team’s approach and told us concerns raised by them were listened to. Staff told us their professional learning was continuously updated through training, sharing best practice and effective communication to support them to meet people’s changing needs.

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.

Staff were proactive in sharing healthcare concerns to ensure people were kept safe and changes in needs were responded to in a timely manner. Staff supported people to have their needs met appropriately by working alongside and following guidance given by health professionals including occupational therapists, district nurses and GPs.

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 told us they felt safe and staff understood how to keep them safe in a way they were comfortable with. One person told us, “It’s all fine. No issues. They [staff] know what they’re doing.”

Staff had completed safeguarding training and were able to give examples of a safeguarding situation and how to report any concerns within the service and to external organisations where needed. One member of staff shared, “If I suspected abuse or harm, I would report it immediately to my manager and follow PentaCare’s safeguarding policy. I understand the importance of acting quickly and documenting concerns clearly. If necessary, I am aware concerns can also be reported to [local authority safeguarding team] or the CQC.

Records showed the registered manager had reported safeguarding concerns to the relevant authorities and where applicable had cooperated with investigations and conducted lessons learnt to prevent reoccurrence. Outcomes of these were cascaded to staff to support best practice.

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.

People and relatives were confident that identified risks to people were managed safely. One relative told us, “Overall, we feel that our family member is safe and well-treated by the staff and has taken well to all of them.”

Risk assessments were regularly assessed; they were person centred and specific to people’s individual needs. Where people had mobility support needs, staff followed appropriate risk assessments to help reduce potential harm and provide safe support.

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’s care plan contained an environmental risk assessment which considered the risks to both people and staff in people’s home environment and how these risks should be managed. For example, assessments included how to manage any potential hazards such as accessibility issues and the use of emollient creams which can pose a serious, potentially fatal fire risk because they leave flammable residues on clothing, bedding, and bandages.This helped to ensure people were supported safely.

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.

People and relatives told us staff were well trained and knowledgeable regarding how to support people to meet their individual needs.

Rotas were in place, so people and relatives knew which staff to expect and when. Any changes to the schedule were communicated by the management team to ensure people knew who to expect.

Staff feedback about the rota was positive and described an effective system. A member of staff told us, “We receive our rota in advance, so we know which [people] we will visit and the scheduled times. The rota usually works well, and travel time is considered. This helps us plan our day and provide care without feeling rushed.” Another member of staff shared, “For live-in care, there is usually a schedule arranged beforehand so we know how long we will be staying with a [person].”

There were enough staff employed, who had received relevant training and ongoing support in their role through regular supervisions, appraisals, competency checks and team meetings. Where people had specific medical conditions or specialist needs, we saw that appropriate training was provided to staff to ensure they had the skills needed to meet people’s needs.

Staff told us they felt encouraged in their professional development, and they would recommend working for the service. One member of staff shared, “I feel supported in my role. We have supervisions and opportunities to discuss any concerns or development needs. The management team, especially [registered manager], is approachable, understanding, and willing to listen. I feel comfortable contacting her if I need guidance or advice.”

People were supported by staff who were recruited safely. Satisfactory Disclosure and Barring Service (DBS) checks were required before staff were permitted to work on their own.

People told us when new staff supported them, they were accompanied by a staff member who knew them well so they could be introduced and learn more about how to support the person safely.

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.

Effective systems to help prevent and control infection were in place. Staff had received relevant infection control and food hygiene training and had access to resources and equipment to help them reduce the risk of infections spreading. People told us staff followed good hygiene practices and used personal protective equipment (PPE) when needed. Staff reported they had consistent access to enough PPE.

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.

Staff told us they had received appropriate training and had their competency to administer medicines regularly checked by the management team.

Care plans and risk assessments were in place to guide staff. This included information to guide staff on when they could administer ‘as required’ medicines such as when people expressed pain. Where people were supported with their medicines this was done safely. One relative shared, “My [family member] has been supported with medication for the last 2 weeks. There have not been any issues with administration.”

Medicine administration was recorded on electronic Medication Administration Records (MARs). Systems in place ensured staff were unable to log out of a care call until they had recorded on the MAR, which meant medicine errors were infrequent. Where medicine errors did occur, this was investigated and staff were provided with further training if needed. If medicines were not administered, office staff received an immediate alert to enable them to check the reasons for non-administration and so that they could act where needed.

Management undertook regular medicines audits to monitor the quality of administration, and competency checks were in place to confirm staff were appropriately skilled to administer medicines safely.