CQC report explained · a residential care home
What the CQC found at Pennine Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Rated Good; inspectors found improvements in safety and management, but some recording and care plan work still needed.
This was an unannounced focused inspection on 22 and 29 August 2023. Inspectors looked at Safe and Well-led because concerns had been raised about care quality, accidents and incidents, and leadership. They spoke with people, relatives, staff and a professional, and reviewed care, medicine and management records.
The home was rated Good for Safe and Good for Well-led. Inspectors found enough staff, safe recruitment, better cleanliness, safe infection control and suitable support for people's health needs. People were protected from abuse, and managers reviewed accidents, incidents and risks.
There were still areas being improved. Staff did not always record accidents and incidents consistently. Some medicine records did not explain why medicines were not taken, and some care plans lacked detailed, person-specific guidance. The provider was working on these issues.
The overall rating changed from Requires Improvement at the previous inspection, published in September 2022. The previous breaches of regulations had been addressed, so the provider was no longer in breach at this inspection.
Clean and well maintained
Inspectors found that the home had improved its cleanliness and maintenance. Staff carried out regular cleaning and infection control arrangements were in place.
“Domestic staff were completing regular cleaning tasks around the home.” from the report
Enough staff
Staffing levels matched the home's assessment of people's needs. Inspectors saw staff responding quickly and providing one-to-one support where needed.
“There were enough staff. The registered manager completed regular assessments of people's dependency needs which was then used to calculate the number of care hours required.” from the report
Better management oversight
Managers used audits, daily checks and action plans to identify and address problems. Inspectors found that governance systems were now embedded.
“At this inspection we found the provider had governance systems in place which provided effective oversight of key risk areas within the service, and these were now fully embedded.” from the report
Improvement since the last inspection
The provider had made changes after the previous inspection, including changes to the management structure and improvement plans. Relatives reported noticeable improvements.
“It has seriously improved, big improvements, I have no issues.” from the report
People encouraged to give feedback
The home encouraged feedback from people and relatives. It had created a residents' forum and involved relatives through meetings and surveys.
“A resident's forum had been created and a person using the service assigned as the chair.” from the report
Accident records were inconsistent
needs fixingStaff used different systems to record accidents and incidents. Managers were working to improve this through reminders, meetings and training, but inspectors made a recommendation.
“Different processes were used by staff to record accidents and incidents, which meant concerns about safety were not consistently recorded.” from the report
Medicine records needed more detail
needs fixingIn one unit, staff sometimes recorded only 'other' when people did not take medicines. The reason was not always explained, although extra training and competency checks were being arranged.
“Staff did not always provide further information on why the person did not take their medicine.” from the report
Some care plans lacked personal detail
needs fixingSome care plans did not give staff enough specific guidance about how to support a person when distressed. The provider had an action plan to improve this.
“Some people's care plans needed further information to ensure they were fully supported safely.” from the report
Staff culture and engagement
minorSome staff did not always promote the home's stated positive and inclusive culture. Staff feedback was mixed, and the provider was working to improve support and communication.
“Some staff did not always promote this in their practice; however, the provider had identified this and was working to improve the culture within the service.” from the report
- 01How are you making sure every accident and incident is recorded using the correct process?
- 02What changes have been made to medicine records in the Moorland unit, and how are staff competency checks monitored?
- 03Have all care plans been updated with detailed, person-specific guidance, especially for people who may become distressed?
- 04What action are you taking to improve staff culture and make sure staff feel able to raise concerns with managers?
- 05Which ratings were carried forward from the previous inspection rather than assessed during this visit?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 22 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.
What inspectors found, September 2022
Pennine Care Centre rated Requires Improvement; safety and governance breaches remained, although it improved from Inadequate and left special measures.
This was an unannounced focused inspection on 26 July 2022. Inspectors spoke with people, relatives, staff and a visiting professional. They observed communal areas and checked care records, medicine records and management records.
The home had enough suitably trained staff. People received medicines as prescribed, risks were assessed and safeguarding procedures were followed. Staff were generally kind and respected people's privacy, dignity and everyday choices.
However, some areas were not clean and infection control practices were not always followed. People and relatives were not always involved in care planning. Activities and personalisation were limited, and management systems had not always led to action on known problems.
The overall rating was Requires Improvement. Safe, Caring and Well-led were also rated Requires Improvement. The home had improved from Inadequate and was no longer in special measures, but it remained in breach of Regulations 12 and 17.
Staffing
There were enough staff to meet people's needs, and staffing had improved since the previous inspection. Staff were visible and responded promptly when people needed help.
“There was enough staff to support safe care.” from the report
Risk management
People's risks were assessed and staff had clear guidance. Inspectors saw evidence that actions such as regular repositioning were being completed.
“Risks to people were assessed.” from the report
Medicines
People received their prescribed medicines from trained and competent staff. Records were completed appropriately, including when people refused medicines.
“People received their prescribed medicines safely.” from the report
Respectful care
Staff treated people with kindness and respected their privacy, dignity and everyday choices.
“We observed caring and patient interactions between staff and people.” from the report
Safeguarding
Staff understood how to recognise abuse, and safeguarding referrals and investigations were completed appropriately.
“People were safe from the risk of abuse.” from the report
Cleaning and infection control
seriousSome furniture, walls, fixtures and flooring were not clean. PPE was not always worn correctly, and the laundry and medicine rooms did not meet expected hygiene standards.
“The home was not cleaned to a high standard.” from the report
Medicine storage
seriousThe medicine trolley lock was broken, some medicine cupboards were unlocked and the keys were not kept securely. The manager said these issues were dealt with immediately.
“Medicines were not always stored in line with the providers policy or best guidance.” from the report
Involvement and activities
needs fixingPeople and relatives were not always involved in care planning. Inspectors also saw limited stimulation, and some bedrooms had few personal items.
“People and their relatives were not always involved in decisions about their care.” from the report
Management oversight
seriousAudits identified problems, but action did not always resolve them. Some refurbishment work was incomplete or below standard, and feedback was not always acted on.
“Systems in place to drive improvements were not yet fully embedded.” from the report
- 01What has been done to make sure all areas, including the laundry room and medicine room, are cleaned properly every day?
- 02How are you checking that staff wear PPE correctly and that infection control standards are followed?
- 03Has the medicine trolley lock been repaired, and how are medicine cupboards and keys kept secure now?
- 04How are residents and relatives involved in reviewing care plans and agreeing changes to care?
- 05What activities and personal items are now available to help people spend their time as they choose?
This was an unannounced focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 September 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 Pennine Care Centre
8 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- September 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- September 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- May 2022Inadequatedown from GoodSafe: InadequateCaring: InadequateWell-led: Inadequate
- August 2021GoodSafe: GoodCaring: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2020
Registered with the Care Quality Commission on 30 April 2020.
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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