CQC report explained · a residential care home
What the CQC found at Pennine House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, safeguarding arrangements were understood, medicines were managed safely and there were enough staff to meet people's needs safely.
- Effective?
- Good
- Staff had training and regular refreshers, people's health needs were followed up and restrictions on liberty were legally authorised and reviewed.
- Caring?
- Good
- Inspectors saw kind and respectful relationships. People were involved in choices about their care and were encouraged to become more independent.
- Responsive?
- Good
- Care plans were detailed and regularly reviewed. Support was organised around people's routines, communication needs, preferences and social activities.
- Well-led?
- Good
- Quality checks and incident reviews had improved and were being used to make changes. The previous warning notice about governance had been addressed.
What inspectors found, June 2019
Rated Good; inspectors found safe, kind and personalised care after improvements, but a night staff vacancy was still being covered temporarily.
This was an unannounced follow-up inspection on 9 May 2019. One inspector spoke with people living in the home, staff and healthcare professionals. They also observed care, checked four people's records, medicines records and the home's quality checks.
The home supported people with learning disabilities, autism and complex mental health needs. Inspectors found that risks were assessed, medicines were managed safely, staff were trained and people received kind, respectful and personalised support. Restrictions on people's freedom had the required legal authorisations.
The home had improved from Requires Improvement at the previous inspection in November 2018. All five CQC areas were rated Good at this inspection. The earlier warning notice about governance had been addressed, and no further enforcement was required.
Improved safety planning
Risks, incidents and behaviours that could cause harm were reviewed more consistently. Inspectors found that physical restraint had reduced in number, intensity and duration since the previous inspection.
“At this inspection we found this had improved and risks to people's health and wellbeing were assessed, managed and regularly reviewed.” from the report
Safe medicines support
Medicines were organised, stored and given safely. Staff were trained and their competence was checked.
“Medicines were well organised and people received their medicines when they should.” from the report
Kind and respectful care
Inspectors saw caring interactions and found that people were consulted about what they wanted to do. Staff respected privacy and encouraged independence.
“People had caring, kind supportive relationships with the staff who supported them.” from the report
Personalised support
Care was organised around individual routines, wishes and communication needs. People could receive information in pictures or symbols when needed.
“At this inspection people's needs were met through good organisation and delivery.” from the report
Better leadership and oversight
The home had strengthened its audits, incident reviews and staff communication. Inspectors found that leaders were using these systems to improve care.
“The systems in place to monitor and review the quality of the service were now effective in making improvements.” from the report
Temporary night staff vacancy
needs fixingThere was a vacancy for night staff when inspectors visited. Existing staff were covering it on a rota while recruitment was completed, so families should ask whether this has now been resolved.
“There was a staff vacancy for night times and staff explained how they were covering this on a rota basis so that people continued to receive consistent care from staff who knew them well.” from the report
- 01Has the night staff vacancy been filled, and how are night shifts covered now?
- 02How will staffing levels support each person's usual routines, evening activities and time away from the home?
- 03How are incidents, physical restraint and behaviour support reviewed for the person we are considering placing here?
- 04How are care plans and communication guidance updated when a person's needs or preferences change?
- 05What quality checks and audits are currently being carried out, and how are people and families involved in improvements?
This was an unannounced scheduled follow-up inspection covering all five CQC questions, with the ratings compared with the previous inspection in November 2018. This explanation was written from the published report of 5 June 2019 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, January 2019
Rated Requires Improvement; inspectors found safety and management problems, but the home had improved and was no longer in Special Measures.
This was an unannounced focused inspection on 29 November 2018. Inspectors checked whether improvements had been made in Safe and Well-led after legal requirements were not met at the previous inspection. They spoke with people, staff and a healthcare professional, observed care, checked care plans and medicines records, and reviewed training and quality checks.
The home was not consistently safe. One person was physically restrained without the required legal authority. Risks linked to behaviour and smoking arrangements were not clearly assessed or recorded. Some staff had not completed mental health awareness training, and medicines were not always managed as required.
The home was also not consistently well-led. Its own audits identified important problems, but action was not taken quickly enough. Staffing had improved, recruitment was safe, and people and staff said they felt supported by the manager. Three regulations were breached. The home had previously been in Special Measures, but inspectors found enough improvement for it to leave Special Measures.
Improved staffing
Staffing had become more consistent and was planned around people's individual needs. Extra staff were available when people needed support to go out or have one-to-one time.
“There were enough staff to be able to support people and we saw that they had ample time to spend with people on the day of inspection.” from the report
Safe recruitment
The home followed recruitment checks before staff started work.
“Safe recruitment procedures had been followed.” from the report
Supportive manager
Staff said the manager was approachable and that they received supervision and support. Inspectors also saw the manager spending time with people and knowing them well.
“Staff felt supported by the manager and that they were approachable.” from the report
Cleaner environment
The home was clean and presented well, with cleaning rotas used to maintain hygiene.
“The home was clean and well presented.” from the report
Some positive changes
Inspectors saw that a more stable staff team had helped some people become more settled, with fewer incidents of anxiety or behaviour that challenged.
“We saw that this had a positive impact on some of the people who lived at the home who were more settled with less incidents of anxiety or behaviours that challenged.” from the report
Restraint without legal authority
seriousOne person continued to be physically restrained after the required legal authorisation had not been granted. Inspectors found 15 restraints during eight incidents over the period reviewed.
“Staff had continued to restrain the person for two months after this.” from the report
Poor risk planning
seriousSmoking arrangements and incidents involving behaviour were not clearly recorded or reviewed. Staff gave inconsistent information and there was no written guidance for the smoking arrangement.
“There was no written guidance for staff to follow and no evidence that this arrangement had been made with the consent of the person.” from the report
Medicines not always managed correctly
seriousOne medicine was recorded and given differently from the prescription, and another person's refusal of daily medicine was not referred to the prescriber for a health review.
“Medicines were not always managed to ensure that people received them as required.” from the report
Training gaps
needs fixingMore than one third of staff had not completed mental health awareness training. Staff described the training as only a basic introduction, despite people's complex mental health needs.
“over one third of staff had not completed mental health awareness training.” from the report
- 01How do you now make sure physical restraint is lawful, necessary, recorded and reviewed?
- 02What written guidance is in place for the person's smoking arrangements, and how is their consent recorded?
- 03How do you check that medicines are given as prescribed and that refusals are referred promptly to the prescriber?
- 04How many staff have now completed mental health awareness training, and what further training is planned?
- 05What action was taken after the warning notice and the problems identified by the provider's own audit?
This was an unannounced focused inspection of Safe and Well-led only; the other key-question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 5 January 2019 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 House
3 rated inspections over a year: the service has improved, from Inadequate to Good.
- June 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- December 2018InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2017
Registered with the Care Quality Commission on 29 August 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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