CQC report explained · a residential care home
What the CQC found at Polventon Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found effective safeguarding, clearer risk assessments, enough staff, safe medicines arrangements and suitable infection control measures. People and relatives said they felt safe.
- Effective?
- Good
- This area was not inspected during this visit, so its previous rating was used for the overall rating.
- Caring?
- Good
- This area was not inspected during this visit, so its previous rating was used for the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit, so its previous rating was used for the overall rating.
- Well-led?
- Good
- Inspectors found effective audits and quality checks, clear management responsibilities and a positive culture. Staff, relatives and professionals were positive about the management and care.
What inspectors found, March 2023
Polventon Residential Care Home is Rated Good; inspectors found safe, caring support and improved management systems.
This was an unannounced, focused inspection on 23 February 2023. One inspector spoke with people living in the home, staff, relatives and health and social care professionals. They also checked care records, medicines records, staff files and management records.
The home was rated Good for Safe and Well-led. Inspectors found effective safeguarding, risk assessment, staffing, medicines and infection control arrangements. People and relatives said they felt safe and were positive about the care.
The inspection checked only Safe and Well-led. The ratings for Effective, Caring and Responsive were carried forward from the previous inspection. The overall rating improved from Requires Improvement to Good because earlier problems had been addressed.
People felt safe
The home had effective systems to protect people from abuse. Staff understood how to report concerns and people and relatives said they felt safe.
“The provider had effective systems in place to protect people from abuse and staff had a good understanding of what to do to make sure people were protected from harm.” from the report
Clearer risk management
The home had introduced new risk assessment documents. These explained the risks for each person and the steps staff should take to reduce them.
“The documentation clearly evidence how risks were assessed, and what action was needed to mitigate and minimise risks.” from the report
Enough consistent staff
Inspectors found staffing levels met people's needs. The home had recruited more staff and had not used agency carers since November 2022.
“The provider had recruited more staff since the last inspection and last used agency carers in November 2022.” from the report
Safe medicines
Staff were trained and checked as competent to give medicines. Electronic records, audits and person-centred guidance for medicines given when needed were in place.
“Medicines were managed safely to ensure people received them in accordance with their health needs and the prescriber's instructions.” from the report
Improved oversight
The management team had introduced regular audits and checks. Inspectors found these systems helped identify and act on improvements.
“The provider had implemented effective quality assurance and auditing systems designed to drive improvements in the service's performance.” from the report
Previous regulatory failings
needs fixingThe last inspection found problems with safeguarding, risk management, legal notifications and management oversight. Inspectors found these had been corrected at this inspection, but families may want to ask how the changes are being kept in place.
“At our last inspection we found breaches of the regulations in relation to reporting safeguarding, managing risk, notifications required by law by the Care Quality Commission, and management oversight of the service.” from the report
- 01How do you check that the newer risk assessments remain accurate when a person's needs change?
- 02What checks are now used to make sure safeguarding incidents are reported promptly and correctly?
- 03How do your audits identify problems, and can families see examples of improvements made after an audit?
- 04What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
- 05How do you maintain staffing levels if people's needs change or staff are absent?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 9 March 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, February 2021
Polventon Residential Care Home was rated Requires Improvement; inspectors found kind care and strong infection controls, but serious safeguarding, risk-recording and governance failures.
This was an unannounced inspection on 16 and 21 December 2020. It followed whistleblowing concerns about incidents that had put people at risk. One inspector spoke with eight people and eight staff, and reviewed care, medicines, recruitment and management records.
The home was not always safe. Some incidents were not reported to the right authorities, and risk assessments did not always record important risks or explain how they should be reduced. The home was also not well-led because its checking systems had failed to identify and correct these problems.
There were positive findings too. People said they were happy, staff were attentive and caring, medicines were well managed, staffing was sufficient, and infection control arrangements for COVID-19 were very good.
The overall rating changed from Good at the previous inspection to Requires Improvement. Only Safe and Well-led were inspected at this visit. The other ratings were carried forward from the previous comprehensive inspection.
Kind and attentive staff
People said staff were excellent, and inspectors saw staff supporting people safely, respectfully and with care.
“Staff were observed as attentive, kind and caring.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing COVID-19 infection, including PPE, testing, distancing and cleaning.
“Management of the service had been vigilant in their approach to minimising the risk of Covid 19 infection, and very good procedures were in place to ensure people were protected.” from the report
Medicines management
Medicines were securely stored, checked regularly and supported by complete records and suitable guidance for medicines given when needed.
“Medicine records were fully completed and well organised.” from the report
Staffing and recruitment
People said there were enough staff, and recruitment checks were satisfactory.
“Staff were recruited safely to ensure they were suitable to work in the care sector.” from the report
Positive atmosphere
People and staff described the home positively. Inspectors found it comfortable, warm and friendly.
“On the day of the inspection visit, we felt there was a comfortable, warm, friendly atmosphere at the service.” from the report
Safeguarding incidents not reported
seriousSeveral incidents, including aggression, people leaving the building and frequent accidents, were not reported or were reported late to relevant authorities. Inspectors said this put people at serious risk.
“Records showed there had been a series of incidents which the registered persons had failed to report to the local authority, under multi agency safeguarding procedures.” from the report
Risk assessments were incomplete
seriousImportant risks, including leaving the home, aggressive behaviour and seizures, were not always recorded. Suitable steps were not always taken to reduce the risk of harm.
“The failure of the provider to ensure satisfactory risk assessment procedures, and to always take suitable action to mitigate risks is a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) 2014.” from the report
Weak quality checks
seriousThe home's audits and management systems did not reliably find omissions or make sure problems were put right. Other agencies and CQC identified concerns that the home's own systems had missed.
“The failure of the provider to effectively assess, monitor and improve the quality of the service provided is a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Required notifications missed
seriousThe home did not always notify CQC about incidents that had to be reported by law.
“Failure to report matters notifiable by regulation is a breach of Regulation 18 (Notification of other incidents) of the Care Quality Commission (Registration) Regulations 2009.” from the report
Managerial change
needs fixingThe registered manager had resigned and was expected to leave at the end of February 2021. A new manager was still being recruited at the time of the inspection.
“The registered manager was supported by a deputy manager, and a head of care.” from the report
- 01How are safeguarding incidents now reported to the local authority, CQC, police and other relevant authorities?
- 02How are risks such as people leaving the home, aggression and seizures recorded, reviewed and reduced?
- 03What checks now make sure accidents, incidents and other serious concerns are identified and acted on promptly?
- 04Who is currently managing the home, and what arrangements are in place while a new manager is appointed and registered?
- 05How are people and their representatives informed, supported and given an apology when a serious incident occurs?
This was a focused inspection prompted by safeguarding concerns and covering Safe and Well-led, including infection control; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 19 February 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 Polventon Residential Care Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Polventon Residential Care Home →
- February 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Polventon Residential Care Home →
- March 2018Goodstayed GoodSafe: GoodWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 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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