CQC report explained · a nursing home
What the CQC found at Pirton Grange Specialist Services
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, medicines were managed safely, staffing was sufficient and recruitment checks had improved. The home was clean and had systems to learn from accidents and incidents.
- Effective?
- Good
- People were supported to make choices, and staff understood consent and mental capacity requirements. Staff had relevant training, people's eating and drinking needs were recorded, and health professionals were involved when needed.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Managers had improved quality checks, delegated responsibilities more effectively and monitored incidents, care records and medicines. The provider was also reviewing whether the service was suitable for people with learning disabilities.
What inspectors found, June 2023
Pirton Grange Specialist Services is rated Good; inspectors found clear improvements, but the home is still reviewing whether its size suits people whose main need is learning disability support.
This was an unannounced focused inspection. Inspectors visited on 31 May and 1 June 2023, and inspection activity continued until 2 June. They spoke with people, relatives, staff and a health professional, and checked care records, medicines records, staff files, risk assessments and management records.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. Inspectors found detailed care plans, safer medicines systems, suitable staffing, good infection control and better oversight by managers.
The last inspection had rated the home Requires Improvement and found breaches of regulations. The provider had made enough progress to no longer be in breach. This inspection did not assess Caring or Responsive, so those ratings were carried forward from the previous inspection.
Better care records and risk checks
Care plans and risk assessments were detailed and were updated when people's needs changed. Staff could explain how they supported specific risks.
“People had detailed and comprehensive care plans and risk assessments.” from the report
Safer medicines systems
Staff received medicines training and competency checks. Managers audited medicines records, investigated errors and stored medicines securely.
“Audits of medicine administration records (MAR) were undertaken by management staff to ensure medicines had been managed correctly” from the report
Sufficient and checked staff
Inspectors found enough staff to meet people's needs. Recruitment checks were robust, and checks and oversight of agency staff had improved since the last inspection.
“Our observations showed there were sufficient numbers of staff to meet people's needs.” from the report
Improved management oversight
The management team had introduced extra clinical management roles and used audits and incident reviews to improve care and health outcomes.
“Learning from and responding to concerns had driven improvement in the management and governance of the service.” from the report
Suitability for learning disability support
needs fixingThe provider accepted that the home was large for people whose main need was a learning disability. It was reviewing the service with commissioners and considering alternative provision where appropriate.
“The provider acknowledged the service size was not ideal to people whose primary need was their learning disability as the service was too large” from the report
More proactive family updates
minorThe home planned more engagement with relatives after communication had slowed during the COVID-19 pandemic. One relative said they received quick information about events but wanted more regular updates.
“We get told quickly if something happens but would like more proactive updates.” from the report
- 01What is the current outcome of the review of whether the home's size is suitable for people whose main need is a learning disability?
- 02How will you make sure my relative's care plan and risk assessments are updated when their needs or risks change?
- 03What medicines checks and staff competency checks are carried out, and how are any errors followed up?
- 04How will relatives receive proactive updates and take part in engagement events?
- 05Which Caring and Responsive ratings were carried forward from the previous inspection?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 28 June 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, October 2022
Rated Requires Improvement; inspectors found unsafe risks, incomplete records and weak oversight, although medicines, staffing and day-to-day care had improved in some areas.
This was an unannounced follow-up inspection on 27 and 28 July 2022. Inspectors spoke with people, relatives and staff, reviewed care and medicines records, and checked the home and its management systems.
The home was not consistently safe. Risks linked to self-harm, fire doors, unlocked areas and building work were not always managed. Care records also contained conflicting information, including instructions about thickened drinks.
There were enough staff, but the home relied heavily on agency workers. Medicines management had improved, infection control was satisfactory, and people and relatives were largely positive about kind and attentive staff.
The overall rating stayed Requires Improvement. The home breached Regulation 12 on safe care and treatment and Regulation 17 on good governance. The provider was given a warning notice previously, some parts of which had still not been met.
Medicines
Medicines management had improved. The home had systems to record errors and provide extra training or competency checks when needed.
“There was a system that identified when medicine errors had been made and recorded the actions taken to mitigate the risks or errors reoccurring.” from the report
Staffing
There were enough staff to provide care and support when people needed it. The home was also trying to use consistent agency staff where possible.
“There were enough staff to ensure people received care and support when needed.” from the report
Kind care
Feedback from people and relatives was largely positive. Inspectors saw staff being kind and attentive when providing care.
“Feedback from people that lived there, and their relatives was largely positive.” from the report
Infection control
Inspectors were assured that the home had suitable infection prevention measures, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Self-harm risks
seriousCare records identified self-harm risks, but key information did not always tell staff what to do. Inspectors found that observations were not always completed as required and ligature risks remained.
“Staff we spoke with were unaware of these risks or actions that needed to be taken to manage these risks.” from the report
Fire safety
seriousSome fire doors did not close properly. The home's regular checks had not identified this, leaving people at risk in a fire.
“Some people did not have fire doors that closed properly.” from the report
Environmental hazards
seriousPeople could access areas containing potential hazards, including personal medicines and areas where building work was taking place.
“People had access to areas that had the potential to put them at risk.” from the report
Conflicting care instructions
seriousInformation about people's eating and drinking needs did not always match across records and food preparation areas. This could create a choking risk, particularly for people supported by agency staff.
“There was a risk that staff unfamiliar with the people in the home, could give the wrong amount of thickener creating a choking risk.” from the report
Weak oversight
seriousQuality checks had not found several problems, including gaps in clinical observations, risk management and record keeping. The provider remained in breach of the governance regulation.
“The provider has failed to make and sustain improvements to the service and comply with regulations.” from the report
- 01What has been done to make sure self-harm risks and required observations are clearly recorded and followed by permanent and agency staff?
- 02Have all fire doors now been checked and repaired so that they close properly?
- 03How are areas containing medicines, cleaning products and building work kept inaccessible to people?
- 04How do you make sure instructions about thickened drinks and other eating and drinking needs match in every record and preparation area?
- 05What action has been taken to prevent gaps in clinical observation records and to make quality checks identify problems promptly?
This was a follow-up inspection that assessed Safe, Effective and Well-led; Caring and Responsive were not newly rated and the report says ratings for uninspected questions carry over from the previous inspection. This explanation was written from the published report of 1 October 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 Pirton Grange Specialist Services
6 rated inspections over 8 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Pirton Grange Specialist Services →
- October 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Pirton Grange Specialist Services →
- December 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- December 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Inspected but not ratedEffective: Requires improvement
- March 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 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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