CQC report explained · a residential care home
What the CQC found at Pingley Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, with risk assessments and enough staff in place. Inspectors did find two gaps in medicines records, gaps in temperature recording and some equipment needing cleaning.
- Effective?
- Good
- People's needs were assessed and care was delivered by trained and supervised staff. People received support with food, drink and healthcare, and were offered choices about their care.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. Inspectors saw positive relationships and found that people were involved in decisions about their care.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. The home offered activities, supported communication needs and had a complaints system that checked whether concerns had been resolved.
- Well-led?
- Good
- The management team was described as approachable and open, with systems to monitor quality. Inspectors said these systems needed to become more firmly established to ensure improvement was continuous.
What inspectors found, October 2021
Pingley Court Care Home was rated Good; inspectors found kind, organised care, with some medicines and cleaning records needing attention.
This was an unannounced planned inspection on 15 and 24 September 2021. Two inspectors and an Expert by Experience spoke with people living in the home, relatives, staff, managers and a visiting professional. They also reviewed care records, medicines records, staff files and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment overall, appropriate training, person-centred care, support with food and healthcare, and respectful relationships.
There were some shortfalls. Inspectors found two gaps in medicines administration records, gaps in temperature records, and some equipment that needed cleaning. One staff member's identification check was also incomplete, but this was corrected during the inspection.
The home had improved since a targeted inspection in 2020, when Safe and Well-led were rated Requires Improvement and the provider breached a regulation. At this inspection, the provider was no longer in breach. The overall Good rating means the service met the expected standards at the time of this inspection, but the report still identified areas to keep under review.
Safe staffing
Inspectors found staffing levels appropriate for people's assessed needs. Staff responded to people's needs in a timely way.
“Staffing levels were appropriate to meet the needs of people who used the service.” from the report
Kind and respectful care
People appeared comfortable and relaxed with staff. Staff respected privacy, asked for consent and supported people to make choices.
“Staff interacted with kindness and compassion throughout our inspection, treating people with dignity and respect.” from the report
Personalised support
Care plans included people's preferences, communication needs and important personal information. Activities were offered both in groups and one to one.
“These were person centred and regularly reviewed.” from the report
Improvement since the last inspection
The provider had acted on concerns from the previous inspection. The home was no longer in breach of regulations at this inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Open management
People, relatives and staff described the management team as approachable. The home worked with families and health and care professionals.
“People and staff praised the management team and told us they were approachable and had an 'open door' policy.” from the report
Medicines records
needs fixingInspectors found two gaps in medicines administration records and gaps in temperature recording. No harm was found, and the provider took immediate action.
“We found two gaps in medication administration records and gaps in temperature recording.” from the report
Cleaning and storage
needs fixingSome equipment needed cleaning, including a stand aid. Individual hoist slings had also been left in communal areas, although the manager acted during the inspection.
“We found some equipment needed cleaning.” from the report
Quality checks need embedding
minorThe home's quality systems identified issues and action was taken, but inspectors said the systems needed to become more firmly established for continuous improvement.
“However, these needed to be further embedded, to ensure there was a continuous approach to improving care.” from the report
Small recruitment gap
minorOne staff member did not have the correct identification check recorded. This was corrected on the day of the inspection.
“We found one staff member did not have the correct ID check in place.” from the report
- 01How do you now check that medicines administration records and medicine temperatures are recorded fully every time?
- 02What checks are in place to make sure equipment is cleaned and individual hoist slings are not left in communal areas?
- 03How have you embedded the quality assurance systems so that improvements are checked continuously?
- 04What staffing levels will be in place for my relative's assessed needs, including during busy periods?
- 05How will my relative's personal preferences, communication needs and interests be recorded and used in daily care?
This was a planned inspection covering all five key questions and included infection prevention and control measures; the previous inspection in 2020 was targeted and did not give an overall rating. This explanation was written from the published report of 15 October 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.
What inspectors found, September 2020
Inspected but not rated; Safe and Well-led both Requires Improvement, with recruitment, medicines records and quality checks needing attention.
This was the home's first inspection. Inspectors carried out a focused inspection during the COVID-19 pandemic, looking only at Safe and Well-led. They visited on 11 and 12 August 2020, spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
People said they felt safe and that there were enough staff. Risk assessments and care plans generally explained how to reduce risks. Staff used protective equipment properly, and the home had suitable infection control measures.
Inspectors found that recruitment checks were not always complete. Medicines were mostly managed safely, but some records were incomplete. The home also needed to improve how it learned from incidents and how it checked whether its systems were working.
The service was not given an overall rating because this was a focused inspection. Safe and Well-led were both rated Requires Improvement. The report says the provider was required to send CQC an action plan and that CQC would continue to monitor the home.
People felt safe
People and relatives told inspectors they felt safe and well looked after.
“We're happy living here, we feel safe.” from the report
Risk assessments
Care records included assessments of risks such as mobility, medicines, equipment and manual handling, with instructions for staff.
“People's care files included appropriate assessment of risk, which had been conducted in relation to their support needs.” from the report
Infection control
Staff had access to protective equipment, had received training and used it appropriately throughout the home.
“Staff used personal protective equipment (PPE) appropriately throughout the home.” from the report
Accessible management
The management team was available to people, relatives and staff. People and staff felt listened to.
“The management team made themselves easily available to people using the service, relatives and staff.” from the report
Incomplete recruitment checks
seriousEmployment gaps were not always followed up and some identity checks were missing. Inspectors said this was a breach of the recruitment regulation, although they found no evidence that anyone had been harmed.
“Gap's in employment history were not followed up. Staff did not always have the correct ID checks in place.” from the report
Medicines records
needs fixingMedicines were generally managed safely, but records were not always up to date. Body maps and opening dates for some creams, gels and eye ointments were missing.
“People told us they received their medicines however, records were not always kept up to date.” from the report
Learning from incidents
needs fixingThe home recorded accidents and incidents but did not consistently analyse them to prevent them happening again. A care plan had not been updated after incidents involving behaviour that could challenge care.
“There was no overall analysis in place to use these as learning opportunities to prevent future re-occurrence.” from the report
Quality audits
needs fixingThe home's audits did not always identify problems with medicines, recruitment or care plans. Some action dates had passed without clear evidence that the work was completed.
“Audits lacked detailed information about who's documents had been sampled, what actions were required and what had been completed.” from the report
- 01Have all staff recruitment files now been checked for employment gaps, identity checks and other required information?
- 02How are you checking that medicines records, including body maps and opening dates, are complete?
- 03What changes have you made to analyse falls and other incidents and prevent them happening again?
- 04How do your audits now show which records were checked, what action was needed and whether it was completed?
- 05What action did you take in response to the Regulation 19 breach, and can you explain what has changed since the inspection?
This was a focused inspection during which CQC looked only at Safe and Well-led, so the other three key questions were not assessed and there was no overall rating. This explanation was written from the published report of 10 September 2020 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 Pingley Court Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- October 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020Inspected but not ratedSafe: Requires improvementWell-led: Requires improvement
- April 2019
Registered with the Care Quality Commission on 12 April 2019.
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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