Provence 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. This is the first assessment for this service. 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 safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to submitting statutory notifications.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety but did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff recorded incidents promptly, but learning from them was inconsistent. Several examples showed that incident investigations were not always completed or linked to updated care plans. For example, records for one person referenced a head injury, but no matching accident report was found. Some audits contained errors or lacked managerial oversight, and learning was not always embedded. One staff member told us, “We raise things, but nothing seems to change.” Following feedback after the first inspection visit, the provider had started to re‑introduce daily staff ‘huddles’ to strengthen learning and communication.

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.

People moving into and out of the service were supported through appropriate coordination with professionals including GPs, district nurses and other health professionals. Staff ensured hospital and respite information was available and used to prepare for people’s discharge and return. One relative said, “They kept everything organised when [Name] went to hospital and made sure they settled again.” The service offered flexible day care and respite to support transitions into long‑term living.

The provider worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. The registered manager did not share concerns quickly and appropriately.

Safeguarding procedures were in place and staff understood how to recognise abuse and made referrals to the local authority. However, statutory notifications had not been submitted by the registered manager to CQC as required. This meant we were not assured appropriate oversight of abuse or potential abuse was in place. The registered manager’s recording of Deprivation of Liberty Safeguards (DoLS) was inconsistent. This meant we were not assured management of these was robust. This placed people at risk of being unlawfully deprived of their liberty. However, people told us they felt safe, with one person saying, “I am one hundred percent safe here and well looked after.”

The registered manager did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were not always effectively assessed or mitigated. Several people lacked essential risk assessments, and this included missing or incomplete documentation for areas such as bed rails. Call bell risk assessments recorded some people could not use call bells, but alternative methods of obtaining help were not described. Inconsistencies existed between planned care, care plans and risk documentation. Some personalised risk approaches were in place, such as safe smoking guidance and allowing a person to enjoy their evening wine safely. However, positive risk‑taking was not consistently promoted.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Appropriate maintenance checks took place on equipment used to support people, and daily checks of fire exits and routes were carried out by staff. However, environmental checks on the building, including the registered manager’s walkarounds, were inconsistently documented and there was no evidence of simulated fire evacuations having taken place.When we raised this with the provider at the end of our first inspection day they took immediate action. Some aspects of the service were not always dementia friendly, for example, a lack of pictorial menus and dementia-friendly signage in some areas.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing levels were variable and so did not always meet people’s needs. Some people and relatives reported long waits, particularly for toileting and during busy periods. Staff described frequent redeployment to the provider’s domiciliary care service, which staff said left units short. Rotas did not always reflect which staff were deployed to support the domiciliary care service, and call bell response times were sometimes inconsistent.

Staff also described inconsistent managerial visibility. Staff explained the registered manager was rarely present on the units, did not provide hands‑on support, and did not always act on concerns raised. Newer staff felt their induction and training were rushed, meaning they did not always feel equipped to support people effectively. However, recruitment processes were robust and staff received appropriate training. They told us they were supported to develop.

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 home was visibly clean, tidy and odour‑free. Domestic staff followed structured cleaning schedules, and people told us their rooms were “always clean”. Personal protective equipment (PPE) stations were available, and staff used PPE appropriately. Infection prevention and control (IPC) audits, cleaning records and bathroom checks were consistently completed. There were no concerns about hand hygiene facilities. Laundry processes were well‑organised. The service had systems to escalate outbreaks and maintain daily hygiene standards.

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.

Medicines were administered safely, with secure storage and clear recording systems. Staff were knowledgeable and used both electronic and paper processes to ensure accuracy. People told us they received medicines on time and could ask for pain relief when needed. Staff sought GP advice when formulations needed altering. Some ‘as and when required’ (PRN) medicine protocols required more detail, especially for people unable to verbally communicate their needs, and psychotropic medication guidance was not always fully documented. We discussed this with senior staff and were assured these had been rectified immediately.