CQC report explained · a residential care home
What the CQC found at Penlee Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable risk assessments and effective safeguarding arrangements. They found gaps in some medicines records and problems with the medicines refrigerator, but the manager took immediate action and inspectors judged there had been no impact on people.
- Effective?
- Good
- Staff had suitable training and supported people to access health services, eat and drink well and make decisions. Capacity assessments had only just been introduced, so inspectors recommended completing them.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors observed relaxed, respectful interactions and found that people were supported to maintain their dignity, independence and daily choices.
- Responsive?
- Good
- Care plans recorded people's needs, preferences and interests, and staff were updated about changes. People had access to activities and could go out into the community when they chose, with support where needed.
- Well-led?
- Good
- Inspectors found approachable management, regular communication and systems for checking the quality of care. The provider and manager were responding to concerns and making resources available for improvements.
What inspectors found, November 2022
Penlee Residential Care Home is rated Good; inspectors found kind, safe care, with some medicines and record-keeping improvements needed.
This was an unannounced inspection on 26 October 2022. It followed concerns about medicines, consent, staffing and how the home was managed. Inspectors spoke with people, relatives, staff and health professionals. They also reviewed care records, medicines records, staff information and management audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, good infection control and suitable support with health needs. People were treated with kindness, had choices about their daily routines and could take part in activities in the home and community.
There were some gaps in medicines records and medicines fridge checks. The manager acted immediately and inspectors found no impact on people. New capacity assessments had only just started, so inspectors recommended that these were completed. Some paper care records were large and difficult to navigate, and the manager said these would be improved.
Enough staff
Inspectors did not substantiate concerns about staffing levels. They found enough staff to meet people's needs and respond in a timely way.
“There were sufficient numbers of staff employed and on duty to meet people's assessed needs.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed caring interactions and found that people's privacy, dignity and independence were respected.
“People spoke positively about staff and told us they were treated with kindness and compassion.” from the report
Personalised support
Care plans included people's histories, preferences and communication needs. Staff supported people to make choices and continue activities that mattered to them.
“Staff had a good understanding of people's individual needs and provided personalised care.” from the report
Health support
Staff worked with health professionals and acted on advice. People were supported with health checks and changes in their health were recognised.
“People's health conditions and social needs were well managed, and the staff engaged with other organisations to help provide consistent care.” from the report
Activities and community access
People could take part in activities at the home and in the community. Inspectors found that concerns about people being unable to go out were not substantiated.
“People had access to a range of activities both in the service and the community.” from the report
Medicines records
needs fixingThere were gaps in records for two people, and stock levels could not confirm whether some doses had been given. The manager took immediate action and inspectors found no impact on people.
“We found a few gaps in records for two people, and we could not verify from the stock levels if these doses had been given.” from the report
Medicines refrigerator checks
needs fixingThe medicines refrigerator was not locked and its temperature was not being monitored suitably during the inspection. The manager acted promptly to correct this.
“The medicines refrigerator was not locked at the time of our inspection and the temperatures were not suitably monitored.” from the report
Capacity assessments
needs fixingNew capacity assessments had only just started. Inspectors recommended completing them so the level of people's mental capacity was clear.
“We recommend the service continues to complete the capacity assessment in order to clarify people's level if mental function.” from the report
Care records were hard to navigate
minorSome paper files contained a lot of dated information and needed archiving. The manager said this would be addressed and that an electronic system was expected in the near future.
“Some files contained a large amount of dated information and we advised the registered manager to address this as those records were difficult to navigate.” from the report
- 01Have all capacity assessments now been completed, and how are best-interest decisions recorded?
- 02What checks are now used to make sure every medicine dose is recorded correctly?
- 03How are medicines requiring cold storage secured, and how are refrigerator temperatures recorded?
- 04Has the care planning system changed from paper records, and how are old information and archived records managed?
- 05How do you check that people can continue to go out and take part in activities that matter to them?
This was an unannounced first inspection of the newly registered service covering all five CQC key questions, prompted by concerns about medicines, consent, staffing and governance. This explanation was written from the published report of 18 November 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 Penlee Residential Care Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Penlee Residential Care Home →
- December 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022
Registered with the Care Quality Commission on 7 July 2022.
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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