CQC report explained · a residential care home
What the CQC found at Penbownder House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Penbownder House rated Requires Improvement; inspectors found risks with medicines, care planning, consent and activities.
This was an unannounced focused inspection on 22 November 2022. Inspectors reviewed four care plans and risk assessments, staff records and other management records. They spoke with nine people, six staff, one healthcare professional and five relatives.
The home was not always safe or effective. Medicines records were incomplete, some risks were not properly assessed, and records about legal authorisations were inaccurate. An open sharps bin with used needles was accessible to people living with dementia. Care plans often lacked clear guidance, activities were limited, and meals and daily routines were not always based on people's choices.
The home had enough staff according to its assessment, recruited staff safely and provided training and supervision. People said they felt safe, and staff knew how to report concerns. However, checks by the provider had not found the problems identified by inspectors.
The overall rating changed from Good at the previous inspection, published on 20 September 2018, to Requires Improvement. The inspection covered Safe, Effective and Well-led. The other key question ratings were carried forward from the previous inspection.
Safe recruitment
New staff were recruited through appropriate processes. Inspectors also found that staff received safeguarding training.
“There were appropriate recruitment processes and procedures in place for new staff.” from the report
Staff training and support
Staff received training, induction and supervision. Staff were positive about the support they received from management.
“Staff were provided with training. Updates were provided to help ensure staff could meet people's specific needs.” from the report
Safeguarding awareness
The manager understood responsibilities for raising safeguarding concerns. People said they felt safe and healthcare professionals agreed.
“People told us they felt safe. Healthcare professionals were confident people were safe.” from the report
Accessible environment
The building was spacious and uncluttered, with signs and facilities to support independence and mobility.
“Rooms were spacious, and corridors uncluttered. There were no malodours.” from the report
Medicine safety
seriousSome controlled medicines were missing from the records, and information about other medicines was inaccurate or incomplete. The home did not always record where pain patches were applied.
“Medicines that required stricter controls were not always recorded accurately.” from the report
Unsafe risk management
seriousAn open sharps bin containing used needles and syringes was accessible in the dining room. Care plans also lacked guidance about managing known risks of assault and pressure damage.
“People, who were living with dementia and walking around independently, had easy access to this bin.” from the report
Incomplete consent records
seriousThe home did not have an accurate record of which people had legal authorisations for restrictive care plans.
“The registered manager did not have an accurate overview relating to which people had authorisations in place for restrictive care plans.” from the report
Limited person-centred care
needs fixingActivities were rarely used, some people said they were bored, and meals and daily routines were not always tailored to individual preferences.
“There was very little activity provided for people on the day of this inspection.” from the report
Weak quality checks
needs fixingAudits had not identified concerns with medicines, risks, care plans or DoLS records. Inspectors also found that the task-driven culture was embedded.
“The audits completed were not always effective and had not identified the concerns found at this inspection.” from the report
Infection control and visiting
needs fixingMasks had been stopped without a risk assessment and were not always worn correctly. Visitors were asked to arrange visits in advance, contrary to current guidance at the time.
“This was not in accordance with current guidance and best practice.” from the report
- 01What has been done to correct the controlled medicines records and to make sure pain patches, liquids and creams are recorded safely?
- 02How are risks such as aggression, poor food and drink intake, pressure damage and access to sharps now assessed and monitored?
- 03How do you now check that every restrictive care plan has the correct Mental Capacity Act and DoLS authorisation?
- 04What activities are currently offered, and how are they matched to each person's interests and choices?
- 05How do you make sure people receive their own clothes and have real choices about meals, bathing and daily routines?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were carried forward from the previous inspection. This explanation was written from the published report of 5 January 2023 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, September 2018
Rated Good; inspectors found kind, well-organised care, but medicines and some care guidance were not always followed.
This was an unannounced inspection on 16 July 2018. Inspectors spoke with 22 people, four care staff and members of the management team. They observed care, including the lunchtime meal, and checked care plans, medicine records, staff files, training records and other documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People appeared relaxed and comfortable. Staff knew people well, staffing levels were usually met, and the home had systems for managing risks, complaints, feedback and improvements.
Inspectors found some areas needing attention. Some medicines were not given at the recommended time or with food, and staff lacked enough guidance about covert medicines. Staff did not always follow wheelchair safety guidance, and staff supporting meals were sometimes helping two people while eating themselves.
The home was also rated Good at its previous inspection on 20 June 2016. That earlier inspection found it fully compliant with the regulations and Good in all areas.
Kind and respectful staff
People were comfortable asking staff for help. Inspectors saw staff provide reassurance, protect privacy and spend time with people during activities.
“The atmosphere throughout the service was calm and relaxed.” from the report
Good staffing and training
Planned staffing levels were routinely achieved. Staff received regular training, supervision and support, and recruitment checks had been completed.
“The well-established staff team were sufficiently skilled to meet people's care and support needs.” from the report
Personalised care
Care plans covered people's health, routines, preferences, life history and emotional needs. Staff were guided on how to support independence and communication.
“People's care plans were sufficiently detailed and informative.” from the report
Activities and community access
People could take part in activities inside the home and were supported to go shopping, visit local places and attend a memory café.
“There was a range of activities available within the service for people to engage with.” from the report
Active management
The management team was approachable and used audits, surveys and incident reviews to identify improvements. Staff said they felt supported.
“There were procedures in place to monitor the quality of care the service provided and drive improvements in performance.” from the report
Medicines were not always given correctly
seriousSome medicines were given at a time when food was not normally served, even though they were prescribed with or just after food. Staff also lacked sufficient guidance for giving medicines covertly.
“We found that some people were not receiving their medicines as prescribed.” from the report
Wheelchair safety guidance was not always followed
needs fixingStaff did not always follow the person's care plan when moving them without foot plates. A specialist wheelchair had been ordered to reduce the known risk.
“Staff did not consistently follow this guidance during the inspection.” from the report
Limited attention during some meals
needs fixingInspectors saw staff try to support two people with their meals while eating themselves. This meant staff could not focus fully on the people's dining experience.
“This meant staff were unable to focus on ensuring people had a pleasant dining experience.” from the report
End of life wishes were not always recorded
minorThe home had a system for recording people's end of life preferences, but these details were missing from some care plans reviewed.
“However, this information had not been consistently completed in the care plans we reviewed.” from the report
- 01What changes have you made to ensure medicines that must be taken with food are given at the correct time?
- 02What written guidance do staff now have for giving medicines covertly, and has a pharmacist been involved?
- 03How do you make sure staff follow individual wheelchair and moving guidance every time?
- 04How do you ensure each person receives individual attention and support during meals?
- 05How are people's end of life wishes discussed, recorded and kept up to date?
This was an unannounced comprehensive inspection covering all five CQC questions, and all five ratings were Good. This explanation was written from the published report of 20 September 2018 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 Penbownder House
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- July 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 December 2010.
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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