CQC report explained · a residential care home
What the CQC found at Pennington Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always stored, administered or recorded safely. Care records, risk assessments, fire information and incident records were also not consistently complete.
- Effective?
- Good
- The report does not give a rating for Effective.
- Caring?
- Good
- The report does not give a rating for Caring. Inspectors said most people and relatives were complimentary, but the inspection also found that staff did not always support people in the least restrictive way.
- Responsive?
- Requires improvement
- Care plans were not always personalised or consistent. Some people were not involved in their care plans, communication plans were missing for some people, and some people spent long periods without company or activities.
- Well-led?
- Requires improvement
- Management and quality systems had not identified or corrected important problems with records, fire safety, risk assessments and daily care checks. The provider remained in breach of good governance.
What inspectors found, August 2023
Pennington Court Care Home is rated Requires Improvement; inspectors found risks with medicines, consent, records and quality checks.
This was an unannounced focused inspection on 23 May and 7 June 2023. Inspectors spoke with people, relatives and staff. They observed care and checked care records, medicines, recruitment, training and management records.
The home was not always safe. Medicines were not consistently stored, recorded or checked safely. Some care records were incomplete, risks were not always properly assessed, and information about people's capacity and best interests was not always recorded.
People were generally described as safe and happy, and staff were caring and welcoming. However, some people had to wait for help, spent long periods alone, and were not always involved in their care plans. Quality checks had failed to identify several of the problems inspectors found.
The overall rating remains Requires Improvement, as do Safe, Responsive and Well-led. The report does not give ratings for Effective or Caring. The provider was in breach of three regulations and was asked to provide an action plan.
People generally felt safe
Most people and relatives said they felt safe and were happy living at the home.
“Most people and their relatives told us they were safe at the home and most people we spoke with told us they were happy living there.” from the report
Safeguarding awareness
Staff had received safeguarding training and knew how to report concerns.
“Staff had received safeguarding training and knew how to report this.” from the report
Infection control
Inspectors were assured that infection prevention arrangements were being followed, including the use of protective equipment and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Support for relationships
People were supported to keep in touch with important people, and visitors were welcomed.
“People were encouraged and supported to maintain relationships with people that matter to them.” from the report
Safe recruitment
The home had safe recruitment procedures. Inspectors also found enough staff overall during their visits, although some people experienced waits at busy times.
“Safe recruitment procedures were in place.” from the report
Medicines
seriousMedicines were not always safely recorded, stored, checked or returned. This included incomplete medicine records, incorrect stock checks and unsafe fridge temperatures.
“Fridge temps were not within correct limits. Some medication stock checks were incorrect on day of inspection.” from the report
Consent and restrictions
seriousThe home did not consistently record mental capacity decisions, best-interest decisions or the legal authorisations needed when people's liberty was restricted.
“The principles of the MCA had not been followed.” from the report
Incomplete care records
seriousRecords did not always show that pressure care, cream applications and pad changes had been completed. Some risk and care information was contradictory or missing.
“People were not consistently protected from harm as care intervention records were not always recorded contemporaneously.” from the report
Personalised care
needs fixingSome care plans lacked personal information and clear guidance about people's individual needs, preferences and past lives. Not everyone was involved in planning their care.
“Care plans lacked personal information and guidance, and some contained contradictory information.” from the report
Time and activities
needs fixingSome people spent long periods alone, particularly on the nursing unit. Inspectors also saw people sitting without activities for long periods.
“Many people were nursed in bed, this meat that they spent periods of time alone” from the report
Weak quality checks
needs fixingAudits and management checks had not found several problems, including inaccurate care records, fire safety issues, missing risk reviews and unmonitored call bells.
“Quality assurance processes had not identified all the areas which needed to improve.” from the report
- 01What checks now make sure medicines are stored at the correct temperature, recorded on MAR charts and returned to the pharmacy when no longer needed?
- 02How do you record mental capacity assessments, best-interest decisions and any required Deprivation of Liberty Safeguards applications?
- 03How are pressure care, cream applications, pad changes and other daily interventions checked to make sure records are complete?
- 04How will you make sure every person's care plan reflects their preferences, history, communication needs and current risks?
- 05How are residents' views, call-bell response times and people's access to activities now monitored?
This was an unannounced focused inspection covering the care home and personal care in the extra care housing, with ratings reported for Safe, Responsive and Well-led; the report does not give ratings for Effective or Caring. This explanation was written from the published report of 26 August 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 2021
Rated Requires Improvement, down from Outstanding; inspectors found safety, care records and oversight needed improvement.
This was an unannounced focused inspection. Inspectors visited on 27 May and 10 June 2021, with inspection activity ending on 24 June. They spoke with people, relatives, staff and health professionals. They observed care and checked care, medicines, staffing and management records.
Inspectors found gaps in records of pressure care, creams, pad changes and fluid intake. Some risk assessments and care plans were incomplete or contradictory. Infection control was not consistent, including cleaning, masks, visitor checks and admission isolation arrangements. Some areas also needed decluttering and deep cleaning.
People and relatives generally said they felt safe and were happy with the care. Medicines were managed safely, and staff sought help from health professionals when people's needs changed. However, the service was rated Requires Improvement overall, with Safe, Responsive and Well-led also rated Requires Improvement. Effective and Caring were not assessed during this focused inspection, so their previous ratings were used.
Medicines
Inspectors found that medicines were received, stored, given and disposed of safely. Staff handling medicines had recent training and competency checks.
“Medicines were received, stored, administered and disposed of safely.” from the report
Health support
Health professionals said staff recognised changing health needs and sought additional professional support.
“the service was particularly good at recognising when people's health needs were changing and where there was a need to refer to professionals for additional support.” from the report
Relationships and activities
People were supported to keep in touch with relatives during the pandemic. An activities coordinator provided group and one-to-one activities, although activity was limited during part of the inspection.
“People were encouraged and supported to maintain relationships with people that matter to them, throughout the pandemic” from the report
Staff support
Staff said they were happy in their work and felt supported through the pandemic.
“Staff at the service were very happy and told us how much they enjoyed their jobs” from the report
Infection control
seriousSome communal areas had not been cleaned sufficiently. Inspectors also found inconsistent use of masks, missing visitor risk assessments and incorrect information about isolation when people were admitted.
“The provider had failed to assess the risk of, and preventing, detecting and controlling the spread of infections.” from the report
Incomplete safety records
seriousRecords did not always show that pressure care, creams, pad changes and fluid monitoring had been completed. Risk assessments did not always give staff clear instructions after incidents or about moving people safely.
“care intervention records were not always recorded contemporaneously” from the report
Weak quality checks
seriousThe home's audits had not found several problems identified by inspectors, including record keeping, infection control and hazards such as trailing wires and very hot water.
“Quality assurance processes had not identified all the areas which needed to improve.” from the report
Complaints and care planning
needs fixingInformal complaints were not always recorded, the complaints policy was out of date and some care plans contained contradictory information. End of life plans were not yet sufficiently detailed.
“The complaints policy was out of date and contained information that was no longer relevant to the current service.” from the report
- 01What action has been taken to make sure care records for pressure care, creams, pad changes and fluid intake are complete?
- 02How do you make sure agency and bank staff understand each person's moving and handling, clinical and dietary needs before providing care?
- 03What changes have been made to infection control, including cleaning, face masks, visitor checks and isolation on admission?
- 04How are informal complaints now recorded, investigated and used to improve the service?
- 05How are quality audits checked to ensure that safety hazards and care record problems are found and corrected promptly?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 4 September 2021 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 Pennington Court Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2021Requires improvementdown from OutstandingSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2018Outstandingup from GoodSafe: GoodResponsive: OutstandingWell-led: Outstanding
- February 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
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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