CQC report explained · a residential care home
What the CQC found at Pinhay House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and risk assessments and care plans had improved. Inspectors found some unsigned handwritten medicines records, missing checks of some entries, and gaps in fridge temperature records.
- Effective?
- Good
- People's needs were assessed and reviewed, staff training had improved, and staff worked with health professionals. Some weight-reducing diets were not clearly documented.
- Caring?
- Good
- People were treated with dignity and respect by kind staff who knew them well. Staff supported people to make choices, maintain independence and keep in touch with relatives.
- Responsive?
- Requires improvement
- Care had become more personalised, but some routines still shaped how care was delivered. Daily records did not give enough information about people's wellbeing and some newer residents lacked personalised activity information.
- Well-led?
- Good
- Leadership, communication and quality monitoring had improved. The provider sent monthly improvement reports to CQC and worked with local quality and health professionals.
What inspectors found, June 2021
Rated Good overall; inspectors found safe, kind care, but the home was not always responsive to people's individual needs.
Inspectors visited on 28 April 2021. They met the 23 people living at the home, spoke with relatives, staff and health professionals, and reviewed care records, medicines, staffing, training and quality checks.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found people felt safe, staff knew them well, care plans had improved, medicines were generally managed safely, and staff treated people with kindness and respect.
Responsive was rated Requires Improvement. Some care still followed routines rather than people's preferences. Daily records were mainly task-focused, some newer residents did not yet have personalised activity information, and signage was not always helpful for people living with dementia.
The overall rating improved from Requires Improvement at the previous inspection. All five regulations followed up at this inspection were met, so the home was no longer in breach of those regulations.
Improved safety
Risk assessments and care plans gave staff clearer information about preventing harm. Inspectors found improvements in areas including choking risks and medicines management.
“Further improvements had been made in managing people's risks and care plans had detailed up to date information for staff on ways to reduce risks.” from the report
Kind and respectful care
Staff were described as kind and compassionate. They supported people's choices, dignity and independence, and knew how to reassure people who became upset.
“People were treated with dignity and respect and cared for by staff who were kind and compassionate.” from the report
Activities and family contact
People were offered activities seven days a week, including support for individual interests. Staff also helped people keep in touch with relatives during the pandemic.
“The service had an activity co-ordinator team which provided people with support with activities seven days a week.” from the report
Stronger leadership
The manager was visible and approachable, and staff reported better teamwork, communication and morale. Quality checks and improvement plans were being used more effectively.
“Regular monitoring and audits were carried out, for example, audits of medicines, infection control and health and safety.” from the report
Care could still follow routines
needs fixingInspectors found some people were got up, taken downstairs and checked at set times rather than care always being shaped around their preferences. The provider said these practices had since been reviewed.
“We found some examples of where staff worked in a routine orientated manner rather, than in a person- centred way.” from the report
Daily records were task-focused
needs fixingDaily notes did not consistently show how people felt, what they did during the day or whether their needs had been met. Records were also spread across different folders.
“Daily care records were kept, although most entries were still focused on care tasks, rather than about the person's day.” from the report
Some medicines records needed checking
needs fixingSome handwritten medicine records were not signed or checked, which could increase the risk of an incorrect dose or medicine. Some fridge temperature checks were also missing.
“Incorrect handwritten MAR charts could increase risk a person might receive the wrong dose or medicine.” from the report
Environment and activity information
minorSignage was too small or inconsistent to help people living with dementia find rooms. Planned improvements to disabled access to bathing facilities had been delayed, and five newer residents did not yet have personalised activity information.
“Word/symbol signage lacked consistency and where it was used, it was too small to help people living with dementia easily identify their own room, toilet, bathroom and living room areas.” from the report
- 01How will you make sure daily records describe my relative's wellbeing, choices and activities, not just completed care tasks?
- 02How do you make sure routines such as getting up, going downstairs and regular checks fit each person's preferences?
- 03Have the planned improvements to disabled access to baths and showers been completed?
- 04What checks are now in place to make sure handwritten medicine records and fridge temperatures are recorded and reviewed?
- 05Do all residents now have personalised activity information and activities based on their interests?
This was a planned follow-up inspection of five earlier regulatory breaches, with infection prevention and control also checked; the report provides ratings for all five key questions. This explanation was written from the published report of 12 June 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, August 2020
Rated Requires Improvement; safety and leadership had improved, but choking, dehydration and record-keeping risks remained, and the home was no longer in special measures.
Inspectors visited on 02 July 2020 after concerns about moving and handling, eating and drinking, and staff interactions. They reviewed care and medicine records, watched care, spoke with people, relatives, staff and professionals, and checked staffing, training and quality records.
The home had made important improvements since its previous Inadequate rating. Staffing, moving and handling, skin care, nutrition support, safeguarding and quality checks had improved. People and relatives also reported that care and management had improved.
However, inspectors found a choking risk was not safely managed because the correct thickener was unavailable and dietary instructions were inconsistent. Records also did not always show action had been taken when people were at risk of dehydration. Medicines records and quality checks still had gaps.
The overall rating was Requires Improvement. The Safe and Well-led ratings were also Requires Improvement. The inspection did not assess Effective, Caring or Responsive, so those ratings carried over from the previous comprehensive inspection. The home was no longer in special measures.
Improved care information
Care plans and risk assessments were more detailed, personalised and up to date. Staff followed moving and handling and skin care guidance.
“People's risk assessments and care plans provided more detailed and up to date information for staff about how to safely care for each person.” from the report
More consistent staffing
Staffing levels had improved, a long-term night vacancy had been filled and the home no longer relied on agency staff.
“The service was no longer using agency staff.” from the report
Safeguarding
Staff had safeguarding training and understood how to recognise and report abuse. The previous breach in this area had been resolved.
“People were protected from potential abuse and avoidable harm.” from the report
Clean environment
Inspectors found the home clean and free from odours. Staff followed infection control measures during the Covid-19 pandemic.
“People lived in a home which was clean and free from odours.” from the report
Improved culture
Inspectors saw calmer, more person-centred care, with staff engaging with people as individuals and responding to signs of distress.
“The atmosphere was calmer and more relaxed. Care was more person centred, staff were more engaged with people as individuals and there was a reduced focus on tasks.” from the report
Dehydration records
seriousFood and drink records had improved but still had gaps, especially at night. When records showed low fluid intake over several days, they did not always show what action had been taken. This was part of an ongoing breach.
“Where people's records showed they had not drunk much over several days, and were at increased risk of dehydration, care records did not show what action had been taken in response, so risks remained.” from the report
Medicines records
needs fixingThere were some missed signatures on medicine records and gaps in fridge temperature checks. Protocols for some as-required medicines were also not in place at the time of inspection.
“Although there were still a few missed signatures to confirm whether or not prescribed medicines had been given.” from the report
Shallow care plan reviews
minorMonthly reviews were taking place, but they often recorded 'no change' even when circumstances had changed. Inspectors made a recommendation for more meaningful reviews.
“Care plans were reviewed monthly, but reviews were mostly cursory.” from the report
- 01How do you now make sure each person with swallowing difficulties receives the correct food texture and thickened drinks every time?
- 02How are low fluid intake and possible dehydration identified, recorded and acted on, including at night?
- 03What checks are now used to make sure medicine administration records are fully signed and medicine fridge temperatures are recorded?
- 04How do monthly care plan reviews record real changes in a person's needs rather than simply stating 'no change'?
- 05What action has been completed to address the ongoing breaches of Regulations 12 and 17?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not assessed and their previous ratings carried over from the last comprehensive inspection. This explanation was written from the published report of 1 August 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 Pinhay House Residential Care Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- June 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at Pinhay House Residential Care Home →
- August 2020Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Pinhay House Residential Care Home →
- January 2020Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016Inspected but not ratedSafe: Requires improvementEffective: Good
- June 2016Inspected but not ratedSafe: InadequateEffective: Requires improvement
- June 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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