Pinglenook Residential Home

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 newly registered service for this provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about areas of environmental safety.

This service scored 62 (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 when incidents and accidents occurred in the service. Our review of records of previous incidents and accidents confirmed they were investigated, reported to the relevant agencies and recorded openly and honestly. Discussions we held with staff confirmed they understood safety concerns and reported them promptly.

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. Processes in place allowed for staff to know when and how to contact relevant health professionals.

People’s care records contained up to date information so this could be shared with relevant professionals. The management team worked positively with the local authority and health professionals.

We spoke with two health professionals during the assessment. A community nurse told us, “I have no concerns with the care and treatment people receive here. Staff follow guidance and recommendations I provide to them.” A GP told us, “I am satisfied from a medical perspective the service contacts us appropriately and timely.

People were protected from the risk of harm and abuse as much as practicably possible. Systems and processes in place supported this. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The provider had implemented the Herbert Protocol. This is an initiative for any person with dementia who goes missing by ensuring other agencies have the right information available to them so that a search for a person can be targeted appropriately. Staff practice and training enabled people right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns promptly with statutory agencies and worked in partnership with them ensuring any safeguarding matters raised were investigated and recorded.

Everyone we spoke with told us they felt safe. One person told us, “I feel very safe here. A relative told us, “We visit regularly and feel [name] is safe and well cared for.”

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 to people’s health and well-being had been assessed and plans of care were developed to manage and mitigate risks. People and their relatives were involved in this process. When people’s needs changed care records were updated to reflect these changes.

Staff we spoke with confirmed they knew potential risks related to people’s care and support, and how to manage these appropriately. One told us, “I have access to everyone’s dietary requirements so I can prepare their meals safely. If there are any changes, I’m informed of these.”

The provider did not always detect and control potential risks in the environment. Some aspects of the service were not maintained effectively. We found some bedroom wardrobes not secured to walls which can pose a risk of these falling on people. We also found some bedroom furniture was in disrepair and needed replacing. The provider addressed these issues during and immediately after the assessment. Other aspects of the environment were managed and maintained 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.

The provider reviewed their dependency tool frequently to ensure there were enough staff deployed to meet people’s assessed needs. Staff were provided with the opportunity to have staff meetings and one to one supervision to discuss any concerns or training needs.

Many people and relatives we spoke with confirmed they were satisfied with staffing levels. One person told us, “They seem to cope well and are a good team.” A relative said, “The staff are very good, almost excellent. It’s one of the reasons I’ve kept [family member] here. The staffing levels can vary but generally things seem ok.” Staff were visible during our visits to the service and responding to people’s requests for assistance promptly.

Staff were recruited safely. This included a Disclosure and Barring Service (DBS) check of all staff. These checks help employers decide if a person is suitable for their role.

We observed domestic staff undertaking their cleaning duties during the assessment, but we found gaps in the completion of some daily cleaning schedules. This meant it was unclear whether cleaning had or had not been undertaken on these days.

On the first and third day of the assessment the clinical waste bin was not secured. There was no process in place that included checks of the clinical waste bin. Staff had completed Infection Prevention Control (IPC) training. They wore personal protective equipment (PPE) such as gloves and aprons when required and these were disposed securely within clinical waste bins in the service.

The provider knew their responsibilities to inform relevant agencies of any outbreak of a contagious disease at the service and reduce the number of non-essential visitors to the s reducing the risk of the spread of infection.

The home was clean and tidy throughout with no malodours. People and relatives raised no concerns in relation to the cleanliness of the service.

The provider ensured medicines were managed safely and treatments were safe and met people’s needs. People told us they always received their medicines at the right time including any 'as and when required' medicine, such as pain relief medicine. One person told us, "Yes I get all the medicines I should do. The carers wait with me while I take them.”

Staff who administered medicines had received the requisite training and told us about the policies and procedures in place and observations of a medicines round confirmed they followed these.

Processes in place for any administrative error and follow up actions such as contacting a GP for advice and recording and reporting of these events were robust. The medicines room and fridges were temperature controlled and were checked daily. Where controlled drugs were prescribed, national legal requirements were followed, such as being stored in a locked cupboard separate from other medicines and being recorded in a register which required two staff to sign for upon each administration.