CQC report explained · a residential care home
What the CQC found at Penley Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Penley Grange was rated Inadequate and placed in special measures; inspectors found serious problems with safety, staffing, care planning and management.
This was an unannounced inspection carried out over five dates in April and May 2022. Inspectors observed or communicated with all five people living at the home, spoke with relatives and 19 staff, and checked care, medicine, recruitment and management records.
Inspectors found people were at risk of avoidable harm. Safeguarding concerns and incidents were not always reported or investigated promptly. Risk assessments, medicines systems, staffing arrangements, infection control and the building were not managed well enough.
Care was not consistently kind, respectful or suited to people's communication needs. People had limited choices about food and activities, and care plans did not fully describe their needs, preferences or goals. Inspectors also found problems with nutrition and choking risk management.
The overall rating fell from Good at the previous inspection, published in November 2017, to Inadequate. The home was placed in special measures, and the provider was required to produce an action plan and make significant improvements.
Some staff recognised safeguarding risks
One staff member showed a good understanding of signs of abuse and how to escalate concerns.
“One staff member demonstrated a good understanding about signs of abuse, explaining they would pay attention to concerns such as unexplained bruising or changes in behaviour.” from the report
Some staff responded to immediate risks
Inspectors saw staff help a person safely return to the ground floor and negotiate steps into the garden.
“We did observe examples of staff responding to risk.” from the report
Some dietary arrangements were in place
A person's food intolerance was recognised, and their food was stored separately.
“One person had a food intolerance. We observed their foods were stored separately, including a separate container in the freezer.” from the report
Relatives were involved in some decisions
Relatives said they had generally been involved in important decisions, although communication was not consistent.
“People's relatives told us they had generally been involved in key decision making” from the report
People were at risk of harm
seriousSafeguarding concerns were not always logged, investigated or reported promptly. Staff did not consistently use preventative strategies when people showed distressed or physically harmful behaviour.
“People did not always live safely. This was because the service did not assess, monitor or manage people's safety well, including risks of abuse and risks posed by the behaviours of people using the service.” from the report
Risk records were incomplete
seriousRisk assessments were missing, out of date or lacked enough detail. Staff could therefore receive unclear or conflicting instructions about how to keep people safe.
“Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.” from the report
Staffing and recruitment were unsafe
seriousRecruitment checks were incomplete, agency staff did not always have relevant training, and staffing levels and deployment did not consistently match people's needs.
“We were not assured enough suitably qualified, competent and experienced staff were deployed to safely meet people's needs.” from the report
Food and drink choices were limited
seriousPeople were generally given the same meals and were not consistently offered choices. Some care plans and staff practice did not properly manage choking risks or follow professional guidance.
“People were not offered day to day choices.” from the report
The environment was poorly maintained
needs fixingInspectors found damaged and damp areas, broken bathroom fittings, uncovered radiators and other potential safety hazards.
“The service's environment was poorly maintained. Paintwork appeared damaged, dirty, damp and mouldy in places.” from the report
Management oversight was weak
seriousAudits and incident systems did not identify or act on important problems. Improvements had started but were not yet embedded.
“Governance processes had not been operated effectively to keep people safe, provide good quality care and protect people's rights.” from the report
- 01What safeguarding concerns or incidents have occurred since the inspection, and how were they reported, investigated and reviewed?
- 02How many suitably trained staff are on each shift, including agency staff, and how are they matched to each person's needs?
- 03Have all care plans and risk assessments been rewritten, including behaviour, falls, epilepsy, choking and moving and handling risks?
- 04What changes have been made to medicines checks, staff training and competency assessments?
- 05Which building, fire safety and infection control problems identified by inspectors have been fixed, and how is this checked?
This was an unannounced inspection covering all five key questions, the care provided and the premises, with infection prevention and control also checked. This explanation was written from the published report of 6 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, November 2017
Penley Grange was rated Good; inspectors found safe, caring support and improvements since the previous inspection, with occasional medicines coding errors.
Inspectors visited on 19 and 22 September 2017. The first visit was unannounced. They observed care, checked records and spoke with relatives, staff, a visiting professional and the manager. They could not speak directly with residents because of their complex communication needs.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found safe medicines management overall, enough staff, suitable training, personalised care plans and respectful support. People were helped to make choices, stay independent, attend healthcare appointments and take part in activities.
The home had improved since the May 2016 inspection, when it had breached regulations about medicines, recruitment, monitoring and records. At this inspection, inspectors found that the relevant requirements were being met. They did note that staff occasionally used the wrong code on a medicines chart, and the manager said this would be addressed.
Kind and respectful care
Inspectors saw staff respond calmly and patiently to people's individual needs. Staff knew how people communicated and used tools such as picture cards, Makaton and an iPad.
“The relationships between staff and people receiving support demonstrated dignity and respect at all times.” from the report
Personalised support
Care plans recorded individual routines, preferences and health needs. People and relatives were involved in reviewing care, and staff supported people to make choices.
“Care plans were personalised and detailed daily routines specific to each person.” from the report
Activities and independence
People were supported to attend community activities, maintain hobbies and choose how they spent their time. The home also supported contact with families.
“People had a range of activities they could be involved in.” from the report
Improved management and records
Inspectors found that earlier problems with monitoring, recruitment, medicines and record keeping had been addressed. Monthly audits were being used to identify and act on concerns.
“Quality monitoring systems were in place to monitor the quality of service being delivered and the running of the service.” from the report
Occasional medicines recording errors
minorInspectors found that staff sometimes used the incorrect code on a medicines chart. The manager said this would be addressed with the staff involved.
“However, we saw that occasionally staff used the incorrect code on the chart.” from the report
- 01What checks are now in place to make sure staff use the correct codes on medicines charts?
- 02How do you make sure care plans stay up to date when a person's health, preferences or communication needs change?
- 03What is the current position of the application for the manager to become registered at the home?
- 04How are residents and their relatives involved in care reviews and decisions about activities?
- 05How do you monitor people's weight and respond if someone begins to lose weight?
This was an unannounced comprehensive inspection covering all five CQC questions; residents were not interviewed directly because of their complex communication needs. This explanation was written from the published report of 8 November 2017 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 Penley Grange
3 rated inspections over 7 years: the service has slipped, from Requires improvement to Inadequate.
- January 2023Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2015
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 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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