CQC report explained · a residential care home
What the CQC found at Penley View
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments were not always updated, some staff did not understand important health risks, and medicines records and staff recruitment checks had gaps. The home had improved its approach to incidents, safeguarding and infection control.
- Effective?
- Requires improvement
- Care plans were generally personalised and health support had improved. However, training and competency checks were incomplete for some specialist tasks, and some mental capacity and oral care records were not clear or complete.
- Caring?
- Good
- Staff were kind, patient and respectful. People were supported to make choices, communicate in their own way, and have privacy and dignity.
- Responsive?
- Good
- People received personalised support and could keep in touch with family and friends. They took part in some chosen activities, but records did not show enough encouragement to try new activities or develop skills.
- Well-led?
- Requires improvement
- Management had made improvements, but quality checks did not identify all the problems found by inspectors. Records were not always accurate or complete, and staff views about management were mixed.
What inspectors found, May 2023
Rated Requires Improvement; care was kind and responsive, but safety, staff checks, medicines and oversight still needed improvement.
Inspectors visited without notice on 2 and 6 February 2023. They observed care, checked records, reviewed medicines and recruitment files, spoke with staff and relatives, and contacted other professionals.
There had been clear improvement since the previous inspection, which was rated Inadequate. People were treated kindly, involved in their care and supported to communicate, stay in touch with family and take part in some activities.
However, important safety systems were still not reliable. Risk records were not always reviewed, medicines records had gaps, and required recruitment checks were missing for some staff. The provider's checks on quality and records did not identify all these problems.
The overall rating was Requires Improvement. Safe, Effective and Well-led were Requires Improvement. Caring and Responsive were Good. The home had been in Special Measures since May 2022, but it was no longer in Special Measures after this inspection.
Kind and respectful care
Staff understood people's communication styles and individual needs. Inspectors saw staff being patient, calm and attentive, while respecting privacy and personal choices.
“People received kind and compassionate care from staff who used positive, respectful language and means of communication which people responded well to.” from the report
Personalised support
Care plans reflected people's needs, preferences, strengths and longer-term goals. People and those important to them were involved in reviewing the plans.
“People had care and support plans that were personalised, holistic, strengths-based and reflected their needs and aspirations, including physical and mental health needs.” from the report
Improved health support
People were supported to attend health checks and work with health professionals. Support with nutrition and hydration had improved since the previous inspection.
“Staff worked with other services and professionals. People were referred to health care professionals to support their well-being and help them to live healthy lives.” from the report
Better response to incidents
The home had improved how it reviewed accidents and incidents. It introduced discussions with staff about lessons learned and actions to prevent problems happening again.
“Processes and practice had been reviewed and improved to effectively review and respond to incidents and accidents to mitigate risk and make improvements to the service.” from the report
Risk management
seriousSome risks were not monitored consistently. Weight checks were missed, risk assessments were not always reviewed monthly, and not all staff understood swallowing and choking risks.
“The provider did not consistently operate effective systems to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Medicines records and checks
seriousRecords for as-required and topical medicines were incomplete or inaccurate. Some staff who administered medicines had not had the required training and competency checks.
“The registered person did not ensure the proper and safe management of medicines.” from the report
Recruitment checks
seriousFive staff files did not contain all required information, including full employment histories and checks about previous conduct and reasons for leaving. This created a risk that unsuitable staff could work at the home.
“Failing to obtain all of the required recruitment information before allowing staff to work, placed people at risk of receiving care from unsuitable staff.” from the report
Staff training and deployment
needs fixingSome mandatory and specialist training was incomplete. Staff and professionals gave mixed views about staffing levels, staff skills and whether people could always receive timely support.
“Professionals felt there was still a concern about the staff mix ratio and who was actually competent to deliver delegated health tasks.” from the report
Quality and record keeping
seriousThe provider's quality checks did not identify all the issues found during inspection. Records about people's distress, delegated tasks and other care and management matters were not always complete or accurate.
“The provider's quality assurance systems did not identify concerns we found during this inspection which are described throughout this report.” from the report
Activities
needs fixingPeople took part in some outings, but records did not show enough support to try new activities, build skills or pursue interests with people who shared them.
“However, the records did not evidence that staff were encouraging people, at their own pace, to try new things and to develop their skills.” from the report
- 01What action has been taken to complete and audit all required recruitment checks for staff?
- 02How are risk assessments reviewed now, and how do you check that staff understand risks such as swallowing and choking?
- 03How do you check that every member of staff administering medicines is trained and assessed as competent?
- 04What has changed in staff deployment so people can go out or receive specialist support without delays?
- 05What activities and community opportunities are now available, and how are they recorded and reviewed against each person's goals?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control, after the previous Inadequate rating and enforcement action. This explanation was written from the published report of 26 May 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, March 2023
Rated Inadequate and placed in special measures; inspectors found widespread risks, unlawful restrictions and serious failures in care and leadership.
This was an unannounced inspection after safeguarding concerns about nutrition, delayed medical treatment, staff interactions, staffing, training and management oversight. Inspectors visited on several dates, spoke with relatives, staff and professionals, observed care, and checked care, medicines, staffing and management records.
All five areas were rated Inadequate: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were at risk of avoidable harm. Risks were not managed properly, safeguarding concerns and injuries were not always reported or investigated, staffing and training were not sufficient, and care plans did not consistently reflect people's needs.
People were not always treated with dignity or supported to communicate in their preferred way. The home did not properly involve people in decisions or use the least restrictive options. The provider started an urgent action plan and sought outside support, but the report says the home remained in breach of regulations after the previous rating of Requires Improvement.
Outside support was sought
After the inspection, the provider sought external support and started an urgent action plan to reduce risks. Commissioners also placed health and social care professionals at the home around the clock to monitor safety.
“The provider took immediate action to seek external support to address leadership and governance concerns and implemented an urgent action plan to mitigate risks to people's safety and quality of life.” from the report
Relatives were involved
Relatives said they were generally kept informed about changes and involved in reviews of care plans. This was not consistent for unexplained injuries.
“People's relatives felt they were kept informed of changes to their family members needs and were involved in reviews of people's plans.” from the report
Health professionals were involved
People had input from several health and social care specialists in response to particular needs. Inspectors also found that some health and care information was recorded.
“Records showed people received input from a variety of health and social care specialists such as dietitians, occupational therapy and speech and language therapy in response to their specific needs.” from the report
Family contact was supported
People were supported to visit family homes and receive visits. Relatives said staff had helped maintain contact during previous government restrictions.
“We found people were enabled to visit in the community and at their family homes and their relatives were supported to visit them in the care home.” from the report
Some medicine storage was safe
Inspectors found the medicines cabinet was secure and its temperature was checked daily. This did not resolve the wider problems with medicines management.
“Medicines in the medicines cabinet were stored safely and securely and temperature of this medicines storage was monitored and recorded daily.” from the report
People were at risk of harm
seriousThe home did not reliably assess or manage risks. Inspectors found unsafe moving and positioning, delayed medical attention, poor emergency planning and unsafe storage of keys and hazardous substances.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Safeguarding and restrictions
seriousSafeguarding concerns and unexplained injuries were not consistently reported or investigated. Staff used physical restrictions that were not in care plans, and some people were deprived of liberty without the required authorisation.
“Systems and processes were not established and operated effectively to prevent abuse of service users or investigate concerns.” from the report
Insufficiently trained staff
seriousTraining gaps affected moving and handling, infection control, food hygiene, autism, medicines and tube feeding. Agency staff did not consistently have the information or skills needed to support people safely.
“The service did not always ensure enough suitably qualified, competent, skilled and experienced staff were deployed to support people.” from the report
Poor dignity and communication
needs fixingInspectors saw staff giving instructions without warmth, people left exposed during personal care, and bedroom privacy not adequately protected. People were not consistently supported to express their views in their preferred way.
“Staff did not always take action to protect people's dignity.” from the report
Care plans and healthcare follow-up
needs fixingCare plans missed important information about pain, skin care, oral health, relationships, contraception and communication. Recommendations and health checks were not always arranged or followed up.
“The service did not ensure that care plans fully identified or met people's needs.” from the report
Weak management systems
seriousThe home did not effectively monitor complaints, incidents, staffing or care quality. Records often did not show what action had been taken or how lessons had been learned.
“Systems were either not established or implemented to monitor events and learn lessons and continually improve the service.” from the report
- 01What has changed since the inspection to make safeguarding referrals, investigations and responses to unexplained injuries reliable?
- 02How do you now make sure every staff member, including agency staff, has the training and competency needed for each person's risks and support needs?
- 03Which people currently have restrictions on movement, personal care or community access, and what legal authorisations and best-interest decisions are in place?
- 04How do you check that care plans include current risks, communication preferences, health needs, nutrition and personal goals?
- 05What system now records complaints, accidents and incidents, and how can you show what action was taken and what was learned?
This was an unannounced inspection of all five key questions, including care, premises, medicines and infection control; the serious injury that prompted part of the inspection was not examined because it was subject to a criminal investigation. This explanation was written from the published report of 1 March 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.
Every inspection of Penley View
3 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- May 2020Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018
Registered with the Care Quality Commission on 30 November 2018.
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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89 live-in carers within about an hour of Buckinghamshire
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Most charge £1,020 to £1,300 a week. 79 can care for a couple. 13 years' experience on average.
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