Pennine Care Centre

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

Our rating for this key question has now changed to requires improvement. We identified 1 breach of the legal regulations. Processes to ensure a learning culture had not yet been fully embedded. People had not always been protected from potential abuse and injury and not all safety incidents had been referred to the local authority safeguarding team. Some areas of the home were not cleaned effectively and not all steps to ensure good infection prevention and control had been taken. However, people’s needs were assessed, and they were helped to achieve their goals and aims. Processes were in place to help manage medicines in line with good practice. There were enough staff to meet people’s needs. Plan to refurbish the environment were underway.

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.

Most people told us they knew and felt able to speak with members of staff and the leadership team. One person told us they had made leaders aware of a situation that they felt could have been managed better and they told us this had led to improvements. Another person told us leaders had spoken with them about a complaint they had made, and they appreciated how leaders had resolved it for them.

Leaders were keen to implement improvements when things had gone wrong and gave examples of where this had happened, this included identifying improvements to staff training. Staff had mixed views on the effectiveness of the training provided. Some staff felt the on-line training was not as useful as face-to-face training. Another staff member felt placing new staff with more experienced staff was not a good way of providing training.

We found incident reports were completed and investigated for some, but not all safety events. Whilst the provider had taken some steps to make improvements in response to previous feedback, processes to help support a learning culture were not yet consistently effective. We found safety events had not always been reported and investigated to help understand their cause and inform people’s care plans. As such, we were not assured that opportunities to reduce risks and improve the safety of people’s care had been fully embedded.

People told us they felt happy and settled living at Pennine Care Centre. One person told us, “I settled really well.” Another person told us, “I have lots of equipment, a special bed, commode, chair and staff use the hoist to transfer me. This helped show people received the support they needed.

Leaders told us they completed their own assessments of people before they moved to the service, and before they moved back to the service if they had been in hospital. They told us this helped them ensure people could safely transition between care settings.

Partners told us the provider accessed other healthcare support for people such as district nurses, GP’s, speech and language therapists and dieticians; partners felt some referrals for support could have been made sooner. Partners felt there were areas where communication and partnership working could improve and that agreed actions for improvement were not always carried out or maintained as agreed. Partners told us the provider had record systems in place designed to help monitor and manage people’s care. However, they had mixed views on whether they were assured these systems worked effectively to ensure people’s safe care.

Care plans showed the involvement of other health care professionals such as the GP. However, we were not assured people’s safety was always safely monitored. This was because not all incidents, such as unexplained bruising, were investigated to understand their cause and help prevent reoccurrence.

People felt safe and not unnecessarily restricted living at Pennine Care Centre. A relative told us, “I feel my loved one is safe and the building is secure, and I am happy with the care my loved one receives.” One person told us, “I can go anywhere within the unit, and I don’t feel restricted.” People knew and felt able to raise any concerns with staff and leaders if this should be needed. One person told us, “I am happy the staff always ask me what I want to do. If I wasn’t happy, I would speak up.”

Leaders were working to improve staffs knowledge on when to make safeguarding referrals to the local authority. However, there was more work to be done.

During our assessment a serious incident occurred that was under investigation by the local authority safeguarding team. This showed people had not always been protected from potential abuse and their rights of privacy and dignity had not always been respected.

Safeguarding processes were not always effective. Safety incidents, such as bruising to people, had not always been shared with the local authority safeguarding team or recorded on the provider’s own safeguarding log. In addition, shortly after our assessment, we reviewed a safeguarding incident that did not detail the injuries that were caused to a person. The injuries were significant and required surgical intervention. Whilst a safeguarding policy and procedure was in place, staff failed to follow this. This failure placed people who used the service at risk.

People told us they felt staff knew them well. One person told us, “I feel totally safe when the staff transport me, they talk to me, and I know what to expect.” Another person said, “The staff help me transfer to the chair and they are very careful not to hurt me.” People felt involved in managing risks associated with their care and support.

Leaders told us they completed assessments of people’s needs before they moved to live at Pennine Care Centre. They told us this helped them identify any risks and what actions to take to reduce risks. We were not assured that staff were reporting safety incidents as they should, with the required detail for leaders to take action to keep people safe.

Records showed that whilst leaders attempted to work with people to be involved in managing their own risks, these were not always accurate or complete and lacked detail and mitigation's to prevent repeated incidents of risk reoccurring. In addition, staff failed to report all incidents of risk as required.

Leaders followed processes to help promote people’s involvement in managing their own risks. This helped to show leaders supported people’s wishes and worked to help them achieve their goals safely. However, when risk incidents had occurred staff did not adhere to their own policies or their regulatory requirements.

People told us they thought their environment was safe. One person told us, “I don’t have any concerns and I have not had any falls, so I guess I am safe.” People told us their own bedrooms were kept clean and tidy. For example, one person said, “I am very happy with my room, I can personalise it and staff come in and clean it.”

Most staff felt people’s home environment was safe. However, some staff told us they had some concerns regarding the stocks of cleaning materials and equipment such as sensor mats and wheelchairs. Leaders told us they were refurbishing the premises and that they had all the equipment they needed to meet people’s needs. Leaders told us they had introduced stock checks of cleaning materials to help ensure they did not run out.

We found 2 wardrobes had not been re-secured following redecoration, this posed a potential safety risk to people using the service. The provider took immediate action to make these safe. There was a fault with the passenger lift that the provider resolved during our assessment. We observed other equipment to be in working order, for example falls sensor mats.

Processes to ensure people were transferred safely were not always effective. One person’s care notes stated they had sustained and injury whist being transferred with a hoist. We found moving and handling care plans contained contradictory information and did not always provide sufficient guidance to staff, for example details of what sling loops to use. The provider’s action plan contained actions designed to address these concerns. However, at the time of our assessment, there had not been sufficient time for improvements to be embedded. We found other routine health and safety checks were in place.

Most people thought there were enough staff and 1 person told us, “There are always staff around.” A couple of people felt there could be more staff in the day however, no-one told us this had affected their care. People told us they felt staff were competent and careful.

Leaders told us they planned staffing levels to meet people’s needs. Staff feedback on whether there were enough staff were mixed. Some staff expressed concern that staffing levels might reduce once involvement from the local authority and the CQC ended.

Whilst care staff were busy, they were able to attend to people’s needs within a reasonable time.

Staff recruitment processes were followed, and staff received supervision and were kept up to date with any important information they needed to help them in their job roles. Staff had been trained in areas relevant to their job roles. Staffing levels were planned to meet people’s needs and records showed staff were deployed in line with these levels. There had been some instances of unplanned staff absence within the catering and cleaning staff. Catering cover had been arranged by the provider however, there had been a few occasions where absences of domestic staff had not been covered.

People were happy with the cleanliness of their home. One relative told us, “The room is always clean and tidy and my loved on is always presentable and clean.” People told us staff wore personal protective equipment (PPE) for example, aprons and gloves at mealtimes.

Leaders told us they had taken action to try and improve the infection prevention and control in the service. however, actions were not always effective due to what we observed during the assessment.

The home had not always been cleaned effectively and this resulted in some malodour. Shower chairs were not free from rust and dirt and areas of shower rooms and toilets had not been effectively cleaned. These issues were discussed with the registered manager who took immediate action to make improvements. We found improvements were required to the cleanliness of the kitchen and some of the kitchen equipment. The device used to reduce risks from flies was found to be broken and a fly was present in the kitchen storeroom. Food storage cupboards required cleaning and a freezer unit was found to need de-frosting. The external bin storage area was not tidy and a clinical waste bin was over-flowing with litter on the floor.

The provider had introduced stock checks on cleaning materials to ensure they did not run out. Relevant policies and procedures were in place for infection prevention and control and the use of personal protective equipment. Processes to ensure effective infection prevention and control had not always been effective as we observed actions to improve cleanliness and hygiene were required in several areas on our first day. However, the provider took action on these and they were resolved by our second day of inspection.

People were pleased with how staff managed their medicines, and they got their medicines when they needed them. For example, one person told us, “I have my medication administered by the nurse. They ask me if I am in pain. If I say yes, they offer me pain relief.” However, one person told us they felt the night staff required more training when administering medication.

Leaders told us they would follow processes to report and investigate any medicines errors. They said they used audits to help identify any thing they needed to improve on. Staff told us they had on 1 occasion found medicines on a windowsill. This had not been reported to leaders in the service. We made the leaders aware, and they told us they would remind staff on the procedures to follow to report any potential medicines errors.

Medicines policies and procedures were in place. We found 1 policy in need of amendment to ensure it reflected the home’s procedures. Medicines audits were in place and helped to identify where any improvements were needed.