CQC report explained · a residential care home
What the CQC found at Pen Inney House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People told inspectors they felt safe, staff understood safeguarding duties, medicines were administered safely and infection control arrangements were suitable. Some risk assessments were missing or not accessible, and staffing was not always enough for preferred routines at busy times.
- Effective?
- Requires improvement
- The home did not consistently follow the legal principles for consent, mental capacity and restrictions on people's liberty. Staff training, food and drink support, and access to healthcare were positive.
- Caring?
- Good
- This question was not rated in this inspection.
- Responsive?
- Good
- This question was not rated in this inspection.
- Well-led?
- Requires improvement
- Management checks did not identify important gaps in monitoring restrictions, fire equipment records and feedback from people and families. The home had approachable managers, supportive staff and links with healthcare and social care professionals.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found people were generally safe, but consent, risk oversight and management systems needed improvement.
The inspection visit took place on 2 November 2022 and was unannounced. One inspector spoke with people, staff, the manager, relatives and healthcare professionals. They reviewed care records, medicines records, staff files, rotas and management records.
People told inspectors they felt safe and trusted staff. Medicines were managed safely, infection control arrangements were suitable, staff training was up to date and people received help with food, drink and healthcare. However, some risk assessments were missing or not accessible, and staff said there were not always enough people to support preferred routines at busy times.
The main concern was how restrictions on people's liberty were managed. The home could not initially provide evidence of mental capacity assessments, best-interest decisions or legal authorisations for restrictions such as pressure mats and locked doors. Fire-check records were also incomplete, and there were no systems for gathering feedback from people and families.
The overall rating changed from Good to Requires Improvement. Safe remained Good, while Effective and Well-led were Requires Improvement. The home was asked for an action plan and will be monitored.
People felt safe
People said they felt safe, and staff understood how to protect people from abuse and harm.
“People told us they felt safe at the service. One person told us; "I feel safe because I know there's always somebody there.” from the report
Medicines were managed safely
Medicines records were completed appropriately. Staff checked timings, stored medicines safely and had clear instructions for medicines given when needed.
“People received their medicines as prescribed. Medicine Administration Records (MARs) were completed appropriately and daily checks were completed to keep a running check of stock.” from the report
Staff were supported
Staff received regular supervision and training. The manager worked alongside staff and staff reported good morale and shared values.
“Staff told us they were well supported. They received regular supervision and the manager frequently worked alongside staff which allowed them to monitor staff skills and values.” from the report
Care was personalised
Staff knew people's needs and preferences. Changes had been made to accommodation where needed, and staff worked with healthcare professionals when people's needs changed.
“People's individual needs and preferences were known and respected.” from the report
Restrictions were not properly checked
seriousSome people were subject to restrictions, including pressure mats and locked external doors. The home could not initially show the required mental capacity assessments, best-interest decisions or legal authorisations.
“There was no evidence people had consented to these restrictions.” from the report
Management oversight was incomplete
needs fixingAudits had not identified the gaps in monitoring restrictions. Fire-check records were incomplete, including records not completed since August 2022, and one equipment fault had no clear recorded follow-up.
“Some of the records in place to evidence these checks, had not been completed since August 2022.” from the report
Risk guidance was not always available
needs fixingSome risks linked to people's health had been identified, but supporting risk assessments and staff guidance were not always available.
“Risk assessments to support the information and guide staff on how to mitigate the risk had not always been developed or were not accessible to staff.” from the report
Families were not routinely asked for feedback
minorThere was no system for gathering views from people using the home or their families. The manager said questionnaires were planned.
“There were no systems in place for gathering the views of people using the service and their families.” from the report
- 01Which residents currently have restrictions such as pressure mats or locked-door arrangements, and where are the mental capacity assessments and best-interest decisions recorded?
- 02How do you check that restrictions remain necessary, proportionate and the least restrictive option?
- 03What has been done to complete fire-equipment checks and follow up the fault identified in the records?
- 04How have missing or inaccessible risk assessments been corrected, and how do staff find the guidance they need?
- 05What action has been taken to improve staffing at busy times and to collect feedback from residents and families?
This was an unannounced inspection prompted by a review of information held by the CQC; Safe, Effective and Well-led were assessed, while Caring and Responsive were not rated and the other ratings carried over from the previous inspection. This explanation was written from the published report of 1 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Pen Inney House was inspected but not rated; inspectors were assured about infection control, visiting arrangements and responses to COVID-19 staffing pressures.
This was a targeted, announced inspection about infection prevention and control, visiting arrangements and staffing pressures during the COVID-19 pandemic. The report says the visit took place on 27 January 2022, although its front page also states 28 January 2022.
Inspectors were assured that the home was using personal protective equipment safely, arranging testing, managing visitors and admissions, and keeping its infection control policy up to date. The home was also meeting the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19.
The report gives an overall result of inspected but not rated. This means it was not a full inspection giving a quality rating. It does not provide current ratings for the other areas of care.
Separate entry arrangements
Different entrances were used for visitors and staff, with the supplies needed before entering the home. This supported infection control.
“Different entrances to the home had been allocated for different reasons.” from the report
Visitor checks and PPE
Staff understood what information to collect from visitors and professionals and what protective equipment they should use.
“Staff understood what information to collect from any visitors or professionals entering the home, and what PPE to ask them to wear.” from the report
Community access
Staff understood the importance of supporting people who wanted to go out into the community to maintain their wellbeing.
“Staff understood the importance of enabling people who wanted to, to go out into the community as often as possible to help maintain their wellbeing.” from the report
Infection control systems
Inspectors were assured that the home used PPE safely, arranged testing, managed admissions and outbreaks, and kept its infection control policy up to date.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, and how do they differ from those inspected in January 2022?
- 02How are current staffing pressures affecting people's care, and what measures are being used to reduce any impact?
- 03How do you support residents who want to go out into the community?
- 04What are the current arrangements for visitors, including checks and protective equipment?
- 05How do you check that visiting professionals meet the current requirements for entering the home?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 16 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pen Inney House
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Registered with the Care Quality Commission on 10 October 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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