Peregrine House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment, we rated this key question Good. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of the legal regulation in relation to person-centred care. People’s care needs were not always fully identified, recorded and provided in line with their specific care needs.

This service scored 61 (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 routinely make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs. Not all care plans were person-centred.

Not all care plans accurately reflected people’s current care needs. This meant there was a risk that relevant information was not captured for use by staff to demonstrate appropriate care was being provided and delivered in line with people’s support needs. The care plan for 1 person did not refer to their specific medical conditions. Where people were living with dementia or a mental health condition, for example, schizophrenia, little to no information was recorded detailing how this affected the person’s activities of daily living.

Though meetings had been held with people about their personal preferences relating to social activities and information was recorded within their individual care plan, people’s experience did not always evidence personalised care that met their specific needs.

Observations as recorded throughout this report demonstrated not all care and support provided by staff for people using the service was person-centred and responsive to meet their needs.

ABC records which help identify patterns, for example, triggers relating to how a person’s anxiety and distress present, and what happens as a result, were poorly completed and did not routinely provide sufficient evidence of staff’s interventions and outcomes.

The provider understood the diverse health and care needs of people and their local communities, so care was joined-up and flexible. However, as already detailed within this report, not all care and support provided by staff for people using the service ensured continuity of care.

Staff worked with other services and involved people’s relatives to provide care and support to people. People received care from the same core group of staff, so they experienced continuity of care as many members of staff had been employed at the service for some considerable time and agency staff had not been utilised at the service for the past 3 months.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Care plans recorded people’s communication needs to guide staff on how best to communicate with the people they supported. The menu and activity programme were in an easy read and pictorial format to enable people with a disability and/or living with dementia to understand the information.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

The provider and registered manager told us they encouraged people who used the service, relatives and staff to share feedback about the quality of the service provided, and what it was like to work at Peregrine House. Annual quality assurance surveys had been forwarded to individuals, inviting them to provide feedback and suggestions for improvement. These were last completed in 2024. The provider confirmed the 2025 survey was scheduled to be undertaken at the end of November 2025.

Feedback was also received and monitored through the provider’s e-reception. The latter is a digital system that allows visitors to provide instant feedback on a tablet while signing ‘in and out’ to a service. This system captured feedback on their experience, which can be used to improve services and demonstrate accountability. This feedback was sent directly to the registered manager, who follows up with the visitor to gain a fuller understanding of any positive comments or concerns raised. Additionally, a member of the organisation’s support office team routinely monitors this information and liaises with the registered manager to ensure that any issues or suggestions are addressed promptly and appropriately.

Arrangements were in place to record, investigate and respond to any complaints raised with the service. People living at Peregrine House and those acting on their behalf were confident about speaking up and raising any concerns. Comments from people using the service and relatives included, “If I was not happy, I would speak to a member of staff” and “We don’t have any complaints but if I was worried, I would go to the registered manager straight away.” An external website for reviewing care homes, recorded 8 complimentary reviews of the service from 1 January 2025.

The provider made sure that most people could access the care, support and treatment they needed when they needed it. However, we were advised of an occasion whereby a person using the service had missed a hospital appointment as staff had not been made aware of the impending appointment.

Discussions with people using the service and those acting on their behalf implied they had not experienced discrimination or inequality. Information available demonstrated the majority of people using the service were able to access services, including a range of external healthcare services and professionals throughout the day, including out of normal hours and in an emergency.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. The service understood the impact inequality could pose on people using the service. The provider was flexible with their approach and support to ensure people had an experience which was fair and just. The staff worked with other professionals to make sure they understood and met people’s individual needs.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

End of life care plans for people were recorded and covered the spiritual, psychological, social and physical aspects of end-of-life care required to ensure the individual received a comfortable, dignified and pain-free death. Where appropriate, ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ [DNACPR] orders were recorded. The service worked in partnership with other professionals, such as the local palliative care team to ensure people received appropriate end of life care. Staff had completed end of life care training.