CQC report explained · a residential care home
What the CQC found at Pencombe Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2019
Rated Requires Improvement; inspectors found kind care, but medicines, safety checks and quality monitoring were not reliable enough.
This was an unannounced follow-up inspection after the previous inspection in June 2018. Inspectors visited on 4, 5 and 8 July 2019. They spoke with people living in the home, relatives, staff and a healthcare professional, and checked care, medicines, staff and management records.
People were generally treated kindly and with dignity. Staff knew people well, responded promptly to call bells and supported people with their health needs. However, medicines records were incomplete or did not match, fire alarm checks were not consistently recorded, and some staff lacked practical moving and handling training.
The home was rated Requires Improvement overall. Caring was rated Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. The home had received this overall rating at the previous inspection, and inspectors said it had been rated Requires Improvement for the last two consecutive inspections.
Kind and respectful care
People and relatives said staff were kind and caring. Inspectors saw friendly interactions, laughter and respect for privacy and dignity.
“Throughout the inspection were saw friendly banter taking place between people and staff members.” from the report
Staff response and staffing levels
People said they did not wait long for help. Inspectors found sufficient staff on duty during the inspection and saw staff respond quickly to an emergency call bell.
“During the inspection an emergency call bell sounded. Staff acted swiftly in response to this.” from the report
Healthcare support
People could access doctors and other healthcare professionals. A healthcare professional said staff worked well with them to provide timely, joined-up care.
“A healthcare professional told us staff worked closely with them and colleagues to ensure people's needs were effectively met in a timely way” from the report
Activities and communication
People had activities, outings and entertainment available. The home used pictorial menus and signs, and had large-print books.
“We saw people sat outside with members of staff enjoying the summer sun.” from the report
Medicines records and checks
seriousMedicines were not always safely managed. Records had gaps, did not always match, and did not always show the dose given or provide guidance for medicines taken when needed.
“The administration of people's medicines was not always safe and so put people at unnecessary risk.” from the report
Fire safety checks
seriousWeekly fire alarm testing had not happened consistently. Records also did not show which call point had been tested.
“Fire safety records showed the provider's check to test the fire alarm on a weekly basis had not happened on a consistent basis” from the report
Meal-time support
needs fixingSome people were supported to eat in a way inspectors said was not person-centred. One staff member assisted two people at once, sometimes standing over people and offering little conversation.
“This is not person-centred care.” from the report
Quality monitoring
seriousAudits had not found important problems with medicines, fire safety, staff training and follow-up of pain concerns. This meant the provider did not identify risks early enough.
“Systems were not robust enough to ensure the quality of the service was suitably well led.” from the report
Staff training records
needs fixingThere were gaps in training records, including practical moving and handling training. The manager temporarily changed the rota to reduce risk until training could be completed.
“Some staff who were working together had not received refresher or actual practical training by a person qualified to carry this out.” from the report
- 01What changes have you made to medicines records, controlled-drug records and PRN guidance since this inspection?
- 02How do you now check that fire alarms are tested weekly and that all call points are covered?
- 03How do you make sure staff assisting people to eat provide one-to-one, person-centred support?
- 04Which staff have completed practical moving and handling training, and how do you check that training remains up to date?
- 05How are pain concerns from surveys or daily care now reviewed and acted on?
This was a follow-up inspection to check action from the previous inspection; all five questions were rated, with Safe deteriorating from Good to Requires Improvement and Effective, Responsive and Well-led remaining Requires Improvement. This explanation was written from the published report of 11 September 2019 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, July 2018
Rated Requires Improvement; inspectors found safe, kind care but important gaps in personalised care, consent and management checks.
This was an unannounced comprehensive inspection on 20 June 2018, followed by an announced visit on 22 June 2018. Inspectors observed care, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Caring. Inspectors found medicines were managed safely, staffing levels were enough, people were protected from abuse, and staff treated people with kindness, respect and compassion.
The home was rated Requires Improvement for Effective, Responsive and Well-led. Inspectors found that best-interest decisions were not properly recorded, some care plans and risk assessments were inaccurate or incomplete, and specialist advice was not obtained for people with swallowing, diabetes or weight-loss concerns.
The overall rating of Requires Improvement means the home was not consistently meeting the required standards. Three regulations were breached, and a warning notice was issued about the home's governance and records.
Safe medicines
Inspectors found people were protected from risks linked to medicines. Administration records were complete, and staff had training and competency checks.
“These records were up to date without omissions.” from the report
Enough staff
Staffing levels allowed people's needs to be met. Inspectors saw staff spending time talking with people and responding quickly when someone became distressed.
“We found there were sufficient staff meet people's needs.” from the report
Kind and respectful care
Staff interacted with people calmly and compassionately. They supported privacy, dignity, communication and independence.
“We found the interactions between staff and people was caring and respectful at all times in a homely environment.” from the report
Improved safety arrangements
The home had acted on earlier concerns about stairways, recruitment and the environment. Risks of falls were assessed and measures were put in place.
“At this inspection, we found the provider was now meeting the requirements of regulations, having taken action to ensure that the potential for people falling down the stairs had been risk assessed and measures taken to make the stairways safe for people.” from the report
Person-centred care
seriousSome care records did not show what staff should do for blood sugar levels, and a falls assessment had not been updated after a fracture. Specialist advice was not obtained for people with swallowing difficulties or weight loss.
“We were not assured people always received person-centred care and support that reflected their individual needs.” from the report
Consent and best interests
seriousThe home did not properly record formal best-interest decisions for people who lacked capacity, including decisions about vaccinations, bed rails, alarm mats and special diets.
“This did not reflect the requirements of the MCA that any significant decisions made on a person's behalf must be subject to a formal best interest process.” from the report
Weak quality checks and records
seriousThe home's audits did not identify important gaps in care plans and risk assessments. Some records were not accurate or up to date.
“Records were not always up to date and accurate.” from the report
Limited activities and outdoor access
needs fixingInspectors saw limited stimulation during the visit. The garden was insecure, so people could not go outside without staff support, and there was little evidence that residents chose the activities.
“We saw limited opportunities for stimulation during our visit.” from the report
Dementia-friendly environment
needs fixingThe home had added signs, but further improvements were needed. Inspectors found no evidence of dementia-friendly activity resources, and improvement work was ongoing.
“The provider had taken steps to adapt the home for people living with dementia, however further improvements were still required.” from the report
- 01How do you now obtain specialist advice for people at risk of choking, needing a special diet or losing weight?
- 02How are best-interest decisions recorded for people who cannot consent to care, including decisions about bed rails, alarm mats, vaccinations and diets?
- 03How do you check that care plans and falls risk assessments are updated after a change in someone's health or an incident?
- 04What activities are available for a person with dementia, and how are residents involved in choosing them?
- 05What progress has been made with securing and improving the garden and making the home more dementia-friendly?
This was an unannounced comprehensive inspection of all five key questions, with an announced follow-up visit; Safe and Caring improved to Good, while the other three ratings remained Requires Improvement. This explanation was written from the published report of 21 July 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 Pencombe Hall
4 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- September 2019Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
11 live-in carers within about an hour of Herefordshire, County of
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £960 to £1,410 a week. 10 can care for a couple. 8 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.