Pendleton Court Care Home

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were logged on the provider’s electronic system. For each one, staff and management documented what had happened, all actions taken, who had been informed and any learning outcomes. Where necessary, root cause analysis had been completed, to identify triggers and potential causes to support the lessons learned process. A specific lessons learned document was completed for all accidents and incidents, with this information shared across the home. Falls diaries were used to log and track falls. Following a fall, people were closely monitored for 24 to 48 hours, to check for signs or symptoms of a deterioration. The provider’s complaints process had been followed for any formal complaints received, with written responses provided outlining actions taken and outcomes. The provider had apologised if any issues with care had been identified following investigation, in line with duty of candour. We did note verbal concerns were not always recorded on the complaint log and a written response sent, if the complainant had requested their issues were not dealt with formally. We discussed this with the provider, who agreed all complaints would now be dealt with as per policy.

The provider worked with people, relatives 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. Pre-assessment tools were completed, along with a ‘moving in’ assessment to ensure the transition process was successful. Surveys were given to relatives which sought feedback on the support provided around the admission / transition process, if this had been sufficient and what could have been done better.

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. People told us they felt safe and received safe care. Comments included, “I feel happy and safe here” and “It’s very good here…the staff look after us well.” Safeguarding referrals had been made in line with guidance and documented appropriately. Information about safeguarding, falls, accidents and incidents, whistleblowing, complaints and compliments was displayed within the home. This had been created in a way which was accessible to most people. Assessments had been completed with people to determine capacity before Deprivation of Liberty Safeguard (DoLS) applications were made. Overall, the DoLS process was managed correctly with applications and reapplications made within required timescales.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People’s care records contained a range of generic and individual risk assessments, which explained any risks to them and how these would be minimised or managed. Although, it was not documented whether people or a legally appointed representative had been involved in the risk assessment process, the fact they were personalised and specific, suggested their views had been sought. The provider also ensured all aspects of service delivery, including the environment, people, staff and visitors was risk assessed. These assessments were all in date and scheduled to be reviewed in May 2025.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Ongoing safety checks had been completed with certification in place, to confirm utilities and equipment were safe to use. Regular fire safety checks were being completed and logged. The provider used a maintenance manual, to document work required and completed, along with completion of all safety checks.

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. The provider used a system for determining staffing numbers, which was based on people’s needs. Staff rotas were compiled in line with this information. Staff told us enough staff were deployed to meet people’s needs, with any gaps, due to sickness or annual leave, filled by overtime or bank staff. One staff member stated, “There are enough staff [on shift] and we can always get more. If needed, the manager will speak to the bank staff and get somebody in very quickly.” Overall, people reported no concerns with staffing levels or waiting times for care. One person told us, “I think there are enough staff here, they do a good job and look after us well.” Staff were recruited safely, with all required pre-employment checks completed. The induction process for new staff was detailed. This lasted 3 days and included training in key areas required to provide safe care. Ongoing and refresher training was provided and monitored, to ensure staff completed this. From checking training records, we noted completion rates across all training courses was high. Staff received supervision and appraisal in line with the provider’s policy. The registered manager also completed ‘growth conversations’ with staff in addition to this. This ensured staff had the ongoing support needed to carry out their roles safely and effectively.

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. We found the home to be clean, with robust infection prevention and control (IPC) processes in place. We observed housekeeping staff on each floor, with checklists and records in place to evidence good cleaning practice. The home had a designated IPC noticeboard, which contained information on handwashing, use of personal protective equipment, colour coding for cleaning equipment; to stop cross contamination. A copy of the Winter IPC plan was also available for staff, people and relatives to read, which explained the steps the provider had and would take to reduce the risk of infections over this period.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. In some instances, medicines were managed well. For example, people always had a supply of their medicines which meant doses were not missed. Stock checks were made which showed that medicines were accounted for and had been administered as prescribed. We saw that when people needed to be given medicines at specific times, the manufacturers’ directions were followed which meant that people were given their medicines correctly. Information was in place to ensure medicines that needed to be given via a feeding tube were given safely. However, in some instances medicines were not managed safely. For example, when people were prescribed medicines to be taken ‘when required’ the protocols to support their administration were not always detailed enough to ensure they could be administered safely and consistently. The records about creams showed that creams were not always applied as prescribed, and some creams were not stored safely. One person’s medicine was not stored at the correct temperature and was administered for 2 days after its expiry date which meant it may not have been effective. Medicine’s audits were regularly completed but they did not identify these concerns. We found no evidence that people were harmed at the time of the assessment, although harm is not always immediate. However, people were placed at risk of harm by not consistently managing medicines safely.