CQC report explained · a residential care home
What the CQC found at Penn House Residential 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 clean premises. Medicines were administered as prescribed, but one administration had not been recorded and this was not identified at the time.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- Management systems had improved and the previous Regulation 17 breach had ended, but medicines administration records were not being monitored effectively. Further improvement was needed.
What inspectors found, February 2024
Rated Good overall; inspectors found safe, caring support, but medicines records were not always complete and well-led was Requires Improvement.
This was an unannounced focused inspection on 9 January 2024. Inspectors checked Safe and Well-led after concerns about risk management and medicines, and followed up an earlier improvement plan. They spoke with people, relatives and staff, observed care, and checked care, medicines and management records.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, suitable risk plans, clean surroundings and staff who understood safeguarding and infection control. Medicines were given as prescribed, but one missed medicines recording had not been identified or investigated.
The home was rated Requires Improvement for Well-led. Management systems had improved and the home was no longer breaching Regulation 17, but checks on medicines records were still not effective. The overall rating changed from Requires Improvement to Good because ratings for areas not inspected were carried forward from the previous inspection.
Enough staff
Inspectors found staffing levels had improved and were sufficient to support people safely.
“There were enough staff to support people safely.” from the report
Risk management
Risk assessments and care records had improved. Fluid intake and repositioning records were being checked regularly, with concerns escalated when needed.
“At this inspection the provider had made improvements and records were accurately completed.” from the report
Clean and safe environment
The home was clean and well maintained. Staff followed infection control procedures.
“The provider had systems in place to ensure the home was clean and well maintained to minimise the risk of cross infection.” from the report
Positive relationships
People appeared calm and relaxed, and inspectors saw positive interactions between people and staff.
“People were calm and relaxed throughout the inspection. We saw positive interactions between people and staff.” from the report
Open management
Relatives said the manager was approachable and listened to concerns. Feedback from people, relatives and staff was used to make changes.
“There were systems in place to seek peoples, relatives and staff views.” from the report
Medicines records
seriousThe electronic medicines system was not fully embedded. One person's medicines had been given but not recorded on one occasion, and this had not been spotted or investigated.
“The electronic medicines administration system was not effectively monitored to ensure all medicines were recorded when administered.” from the report
Management checks
needs fixingThe home had improved, but management oversight was still not consistent in all areas. Inspectors said further improvement was needed, particularly around medicines monitoring.
“At this inspection the provider had made improvements in these areas, but more improvements were needed.” from the report
- 01What new checks have been introduced to make sure every medicine given is recorded correctly?
- 02How quickly would you identify and investigate a missed medicines entry?
- 03How often are care delivery notes, fluid records and repositioning records checked now?
- 04How do you use people's and relatives' feedback to make changes to the home?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection?
This was a focused inspection of Safe and Well-led only; ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 23 February 2024 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 2023
Penn House Residential Home rated Requires Improvement; inspectors found risks from staffing and weak oversight, with a continued governance breach.
This was an unannounced focused inspection on 25 July 2023. Inspectors looked only at Safe and Well-led, spoke with people, a relative and staff, observed care, and checked records.
People generally felt safe, medicines were managed properly, and staff understood safeguarding. However, there were not always enough staff to help people with meals, drinks and personal care when needed. Fluid monitoring and repositioning were not always followed up when records showed a problem.
The home had been rated Requires Improvement at the previous inspection and has received this rating for three consecutive inspections. The provider remained in breach of Regulation 17 because its systems identified care shortfalls but did not ensure action was taken.
People felt safe
People said they felt safe, and staff knew how to recognise and report abuse.
“People felt safe living at the service and were supported by staff who understood how to protect them from the risk of abuse.” from the report
Medicines were managed safely
Inspectors found that medicines were stored correctly, records were accurate and people received medicines as prescribed.
“Medicine administration records were completed accurately and showed people had their medicines as prescribed.” from the report
Safeguarding arrangements
Staff had safeguarding training and incidents were reported to the appropriate organisations.
“Staff had received training in how to safeguard people from abuse and any incidents which occurred were reported to the appropriate body for investigation.” from the report
Not enough staff at some times
seriousPeople did not always have help with drinks and meals when they needed it. Staff were not always deployed effectively, which limited time for people who were cared for in bed.
“People were not always supported by enough staff to meet their needs.” from the report
Weak oversight
seriousThe provider's systems could identify missed care but did not ensure that staff took action. This left people at risk of dehydration, skin damage and unmet care needs.
“There was still insufficient oversight on the service and the measures in place were not always effective in ensuring actions was taken to address areas of improvement.” from the report
Choices and care plans
needs fixingPeople gave mixed views about whether staff asked about their preferences. Care plans did not consistently record how people liked their care to be provided.
“People's care plans were not person-centred.” from the report
- 01What staffing levels are now in place at each point in the day, and how are they matched to residents' changing needs?
- 02How do you check that people at risk of dehydration meet their fluid targets, and what action is taken when they do not?
- 03How do you make sure repositioning is completed on time and that missed repositioning is acted on immediately?
- 04What changes have been made to care plans so they record each person's preferences and choices?
- 05What progress has been made on the action plan and the warning notice since the inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 30 September 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.
Every inspection of Penn House Residential Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2018GoodSafe: GoodWell-led: Good
- February 2017
Registered with the Care Quality Commission on 17 February 2017.
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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