Pinkneys Road Also known as 87 Pinkneys Road

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. 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 the way safeguarding concerns were managed and staffing.

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 have a proactive and positive culture of safety based on openness and honesty. They did not investigate or report safety events when required. Lessons were not learnt to continually identify and embed good practice.

Although systems were in place to support staff to report and record safety concerns and events when these arose, they were not always effective. One incident that occurred at the service compromised a person’s safety and staff had not reported this to the registered manager or where required within the person’s documentation. The registered manager was not aware of the concern until 2 months after the incident. This meant that the incident had not been investigated, and the cause could not be identified. This was raised with the registered manager during the inspection who advised further training would be given following our findings at the inspection to staff to ensure improved communication and documentation of incidents.

The provider analysed all incidents and accidents on a quarterly basis that occurred at the service to find out what went wrong and how to prevent these from happening again in the future. Due to the incident above, the registered manager advised the regularity of analysis would be reviewed and increased to mitigate the risk of the incident recurring.

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. The registered manager and staff ensured people received support from external healthcare partners. Where required, people had advocates in place to support them to receive care that best met their needs. Where the local authority supported people, there was effective communication between the registered manager and social workers. Relatives told us they felt their relatives were safe living at the service.

Prior to people arriving at the service, the management team advised they would conduct assessments to help ensure they were able to meet the needs of the person and support a smooth transition to the service. The registered manager explained how they worked together with professionals and others, through a collaborative, joined-up approach, to ensure safety and continuity of care was a priority throughout people’s care journey. For example, if the service was preparing for a potential admission, the manager worked together with people, their families, and professionals to gather and create plans of care so they could receive the care and support they needed

During the inspection we reviewed safeguarding concerns raised by the service. One incident had been raised by a member of staff regarding a bruise on a person. This was not investigated or raised as a safeguarding until 2 months later when an audit was conducted. This was discussed with the registered manager who advised this was due to a staff member inputting the information in the incorrect place on the system. However, as the concern was not investigated immediately this put people at risk of harm. The registered manager advised all staff will receive further training in relation to documentation of safeguarding concerns.

The provider had an up-to-date safeguarding policy and procedures in place. Staff told us they were aware of these. The provider kept a log of all safeguarding concerns raised. This included the type of abuse, description of the incident, outcome date closed and reflective practice.

The provider worked with people, relatives and professionals to understand and manage risks. People’s likes and dislikes were regularly taken into account especially when it came to meals and decoration within the home. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. People’s records contained current, up to date guidance for staff about how to manage identified risk to people and keep them safe. Staff understood how risks to people’s safety and wellbeing should be managed, to keep them safe when taking part in activities and events of their choice. Staff told us they had all the information they required in order to meet people’s needs. When people were at home, staff were aware of where people were and remained present and available in case people required their assistance.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. All required environmental checks had been completed on a regular basis including wheelchair, sling and hoist checks. Regular fire drills took place however, there had not been a night time fire drill recently. This put people at risk of not being evacuated quickly if there was a fire in the night. A conversation with night staff had taken place about how the staff would evacuate in the event of a fire. The registered manager told us a night time fire drill would take place in the near future. The home was in the process of being refurbished and redecorated in line with people’s choices and preferences. People had been shown colours for their rooms and had been supported to pick their favourite. Prompt action was taken to address any safety concerns identified. This helped to ensure the environment, and equipment used, remained in good order and safe for use.

The provider made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective support, supervision and development. Staff mostly worked together well to provide safe care that met people’s individual needs. There was no evidence of appraisals having taken place for some staff within the last 3 years. This was confirmed by the registered manager. This meant staff did not have the opportunity to discuss their work life and career objectives with their relevant line managers. Supervisions were due to take place on a regular basis, however some staff had not had a supervision for an extended period of time. This was discussed with the registered manager who stated that they were in the process of arranging supervisions with all staff. There had been previous concerns regarding staff working cohesively together. This had been identified by the current registered manager who had implemented new ways of working to improve this and ensure the best care to people.

All staff had received regular training in subjects the provider identified as mandatory. The provider did not complete Oliver McGowan training in relation to people with a learning disability or autistic people. This is the Government's preferred and recommended training for health and social care staff to undertake to enable providers to meet the requirements of this regulation. However, the provider ensured all staff completed training in relation to people with a learning disability or autistic people on a regular basis.

Relatives and professionals told us they were happy with the staff and felt they knew people well. One relative told us, “I feel the staff look after [Person] well and meet all [their] needs in a dignified manner. The staff are competent in looking after [Person] and consistent in their approach to [Person] … when I visit [Person] there always seems to be enough staff.”

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. People were supported to live in a clean, hygienic environment. Staff received relevant training and knew the processes to follow to minimise the risk and spread of infection. Staff had access to resources and equipment to help them reduce infection risks. Staff maintained cleaning and food safety records to detail measures taken to reduce infection risks. The provider’s infection prevention and control policy was current and reflected national guidance. Managers undertook regular audits and checks on staff’s practice to make sure these were in line with policies and current guidance.During the inspection, we observed staff wearing personal protective equipment appropriately and regular handwashing took place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were processes to help ensure people received their ‘when required’ (PRN) medicines safely and as prescribed. PRN protocols explained what each medicine was for, how the person would communicate they needed the medicine, any side effects and the maximum dose within 24 hours. Stock takes of medicines were completed daily to identify any missed medicines or medicines errors. Risk assessments were in place where required. For example, one person was prescribed a cream that is flammable. An appropriate risk assessment was in place to reduce the risk of fire.