Penniston Barn

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 questiongood. At thisassessmentthe rating has changed torequires 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 relationsafeenvironments.

This service scored 56 (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.Incident reviews were not always effective in promoting learning and preventing recurrence. Recordslargely consistedof chronological accounts of events and focused on what had happened, rather than exploring why incidents occurred. The service had not consistently analysed themes, trends or patterns across incidents, and there was limited evidence of proactive strategies being developed to reduce future risks.

Systems for managing and sharing information about people's care were not always effective. Care planning information was spread across multiple documents, including care plans, Positive Behaviour Support plans and behaviour management plans, and information was not always consistent between records. Some known health risks were not reflected across all relevant documentation, reducing assurance that staff had access to accurate and up-to-date information to support people safely and consistently.

However, there was evidence of multidisciplinary team involvement in people's care and support. Staff worked with relevant health and social care professionals and sought specialist input when required to help meet people's needs and promote positive outcomes.

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 demonstrated a good understanding of their safeguarding responsibilities and were able to clearly describe the actions they would take if they suspected abuse or poor practice.

People were not always supported to manage risks safely because risks associated with their care and living environment had not been consistently assessed, monitored and mitigated. We found environmental hazards, including unsafe adaptations, damaged fixtures, unsecured hazardous substances and fire safety concerns, which increased the risk of potential harm. The provider had not always demonstrated that environmental risks had been fully considered and addressed in line with people's individual needs.

People were not always kept safe because environmental risks had not been consistently identified and addressed. We found hazards including sharp surfaces, unsuitable adaptations for people with known behavioural risks, unsecured hazardous substances, damaged fixtures and concerns relating to fire safety arrangements, including fire doors. Damage was evident in several areas, including walls and wardrobe doors. In addition, communal areas contained numerous staff notices and organisational information which detracted from creating a homely environment for people. A relative said, “[Relative’s] room is a bit bare and barren, they used to have posters up, the room is more practical than homely. The home can look tired at times”

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. There were enough staff deployed to meet people's assessed needs. Staff told us they received regular training and supervision and felt supported to carry out their roles effectively.

People were not always protected from the risk of infection because the provider had not consistently maintained the premises to appropriate standards of cleanliness and repair. We found areas of the service that were damaged or worn, including torn furnishings, damaged flooring and mould within a bathroom, which made effective cleaning more difficult and increased the risk of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not always stored safely. Records showed medicine storage temperatures had exceeded the recommended threshold of 25°C on several occasions. Although temporary air conditioning had been ordered, it had not been delivered at the time of inspection and there was no evidence of interim measures being implemented to mitigate the risk. Pharmacy advice had not been sought to determine whether medicines exposed to elevated temperatures remained safe and effective for use.