Peregrine 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. 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 safe care and treatment. Risks to people’s safety were not always safe, identified and recorded.

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 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. However, lessons were not always learnt to continually identify and embed good practice.

Where supervision records recorded concerns about some members of staff’s performance and practice and improvements were required, there was a lack of information to demonstrate how this was and had been monitored and lessons learned. For example, the supervision record for a senior member of staff referred to them promoting safe working practices, responding, supporting and providing guidance to care staff as part of their role. No actions were cited to record and monitor this. The impact of this meant without learning from events, staff may continue to lack the necessary skills and knowledge to prevent future recurrence and inappropriate care for people using the service.

Staff knew how to record accidents and incidents. These were dealt with as an opportunity to put things right, learn and improve. A member of staff told us they would document information relating to the above and escalate this to senior staff and/or the management team, to ensure any follow up action required was undertaken and lessons learned.

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’s needs were assessed prior to their admission to the service, and this information was used to inform their care plan and associated risk assessments. The registered manager told us about the service’s assessment and admission process. They told us people’s care and support needs were planned where possible with the person, those acting on their behalf and other key partners to ensure continuity of care. A relative confirmed they had been actively involved with their family member’s admission to Peregrine House, stating that an assessment undertaken by the service was completed and they had been given the opportunity to view the service. Another relative told us their family member’s admission to the service had followed discharge from hospital. They told us, “[Family member] was admitted to Peregrine House quite quickly. The Local Authority told me about the place, and I went there to see it.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, staff did not always concentrate on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Incidents occurred during this assessment whereby some people’s safety and quality of care was compromised as recorded within the risk section of this report.

People and their relatives considered themselves and their family member to be safe. A person using the service told us, “Yes, I feel safe, thank you”. Relatives told us, “[Family member] is safe and comfortable”, “[Family member] is safer at Peregrine House than anywhere”, “Peregrine House has done a great job and keeps them [family member] safe and well looked after” and “I have never seen anyone being badly or unkindly treated there.”

The provider and registered manager were aware of their responsibility to notify us and the Local Authority of any allegations or incidents of abuse. Internal safeguarding investigations were completed where appropriate and the management team collaborated with the Local Authority as part of their statutory responsibilities. However, some relatives told us they had not always been given feedback or informed of the outcome of a safeguarding incident for their family member. A relative told us, “The incident was investigated, and I asked to be informed of the outcome. I wasn’t told anything.” Informing family members of the outcome of safeguarding concerns is important formaintaining transparency, building trust, and enabling families to be effective advocates.

Staff were able to tell us about the different types of abuse and what to do to make sure people were protected from harm. Staff told us they would escalate any concerns to the provider, registered manager, Local Authority or Care Quality Commission.

The provider did not ensure all risks to people’s safety and wellbeing were identified or provided enough detail as to how these should be mitigated.

We observed 6 separate incidents during the first day of our assessment whereby two members of staff, consistently performed unsafe moving and handling practices. This referred to staff putting people at potential risk of harm by placing their hands under the person’s underarms or by pulling the person up by their forearms or hands when assisting them with transfers. These practices are unsafe and can cause the person to experience discomfort and injury. Following our feedback, the provider immediately arranged for the provider’s ‘in-house’ moving and handling trainer to complete observations and competencies with staff employed at the service. The provider confirmed that appropriate moving and handling training would also be repeated with staff and additional observations conducted to ensure practices were safe going forward.

A person was observed on the first day of our assessment, eating a snack without staff assistance while maintaining a poor postural position. This was not conducive to them eating easily or safely as their nutrition and hydration care plan recorded they had been assessed by a healthcare professional as requiring staff support whilst eating and a specially textured modified diet. The same person had been observed earlier in the day eating a food item which was considered a choking hazard and not meeting the texture requirements for their modified diet. The above demonstrated staff were not routinely following the person’s dysphagia and choking care plan or risk assessment. Both occurrences placed this person at high choking and aspiration risk. Following our feedback, the provider immediately arranged for staff involved to be given supervision, for staff to receive additional training relating to dysphagia and the importance of people receiving a textured modified diet and for the person’s care plan and risk assessment to be reviewed. Shared learning relating to the above was provided across the service to minimise the risk of further occurrence.

Where people were assessed to be at risk of dehydration and required their fluid intake to be monitored and recorded, records demonstrated their fluid targets were not always maintained and there was a lack of evidence to show what was being done to monitor and address this. The care plan for another person referred to them living with 3 specific medical conditions. The potential risks associated with these conditions were not identified and recorded. This was not an isolated case.

Personal Emergency Evacuation Plans [PEEP] were evident for each person. However, not all plans viewed had considered and identified people’s physical and neurological needs which would affect their ability to safely evacuate, their ability to communicate and understand instructions and where they could be anxious and distressed. A PEEP is a bespoke ‘escape plan’ for individuals who may not be able to reach a place of safety unaided or within a satisfactory period in the event of a fire emergency.

Fire drills were not routinely undertaken for staff, despite the service’s fire risk assessment dated September 2024, highlighting this as an area for improvement. Fire drills are important for staffto ensure they can evacuate vulnerable people safely and efficiently during a fire emergency.

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 and relatives did not express any concern in relation to the safety of the environment.The service was decorated and furnished to a satisfactory standard. People had personalised rooms which supported their individual needs and preferences. There were different areas available for people to use for their preferred activities. Each of the 4 areas had its own communal lounge and dining area. People had access to an outside space that was safe and secure.

Routine environmental and equipment checks were completed to ensure the premises were safe. For example, safety checks were completed relating to the service’s electrical and gas installation system, electric portable appliances throughout the service and fire safety equipment checks. Specialist or adaptive equipment was made available for people’s use to ensure their needs were met.

The provider did not ensure there were enough qualified, skilled and experienced staff that could meet people’s needs. They did not always make sure staff received effective formal supervision and development.

People’s and relatives’ comments relating to staffing levels were variable. Where comments from people using the service and relatives were positive these included, “There is always a member of staff in the main room with the residents and someone spare in case someone needs some help” and “Yes, I think there are enough staff, there seems to be when I visit.” Where less variable comments were made these included, “I’m not sure there are always enough staff”, “They [Peregrine House] could do with a few more staff at times, but then most care homes could”, “There certainly doesn’t seem to be as many staff working there as there used to be” and “There are always new staff. I wonder if they use agency staff because [family member] has a lot of different staff.” We discussed the latter with the registered manager, and they confirmed no agency staff had been utilised at the service for the last 3 months.

The provider used a formal tool to assess people’s dependency needs and this was used to inform the service’s staffing levels. Observations during our assessment demonstrated there were enough staff deployed during the day in line with staffing levels stated by the registered manager. Throughout our visits, call alarms to summon staff assistance were responded to in a timely manner with staff presence evident within communal lounge areas. However, we expressed concerns regarding the lack of social activities promoted for people using the service on the first day of our assessment on Yellow area to meet people’s needs. This was observed to significantly improve on the second day.

Staff had received regular formal supervision. Where staff supervisions were happening and an issue raised about a member of staff’s performance and conduct, there was a lack of information recorded as to how these matters were being monitored and addressed in the longer term.

Staff recruitment records demonstrated relevant checks were completed before a new member of staff started working at the service. This included an application form, written references, proof of identification and Disclosure and Barring Service [DBS] checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Newly employed staff received an induction and were given the opportunity to ‘shadow’ more experienced staff to ensure they understood the routines of the service and their roles and responsibilities.

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.

No people or relatives raised concerns about the cleanliness of the environment. Comments included, “When I visit, the premises seem clean enough”, “It [Peregrine House] is always clean” and “The place is always clean and tidy generally.”

Observations during our visit demonstrated the service was clean, hygienic and odour free. Staff were clear about their roles and responsibilities to ensure people were protected by the prevention and control of infection arrangements at Peregrine House. Staff had access to policies and procedures on infection control and had sufficient Personal Protective Equipment [PPE]. Staff were observed using PPE appropriately and when required.

Audits relating to the service’s infection, prevention and control arrangements were being conducted at regular intervals and demonstrated there was a good level of compliance. Staff had received appropriate infection, prevention and control training.

The provider made sure that medicines management was safe and met people’s needs.

Relative’s comments relating to the management of medicines for their family member were positive. Comments included, “They [staff] do manage their [family member] medication”, “They do all [family member’s] medication and it is working very well at the moment” and “They [staff] cope with their [family member’s] general medication and they always phone me if there are any issues.”

Staff were observed to administer people’s medicines appropriately and in line with current guidance. The medication rounds were evenly spaced out throughout the day to ensure people did not receive their medicines too close together or too late. Observation of staff practice showed staff undertook this task with dignity and respect for the people being supported.

Medicine records were maintained to a good standard, and Medication Administration Records [MAR] demonstrated people received their medicines as they should and in line with the prescriber’s instructions. The service ensured people's behaviour when anxious and distressed was not controlled by excessive and inappropriate use of medicines. PRN [as needed] protocols were in place for all prescribed medicines administered in this manner.

Staff who administered medication were trained and had their competency assessed to ensure they remained competent to undertake this task safely.