CQC report explained · a nursing home
What the CQC found at Ponteland Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems for safeguarding, risk management, medicines, infection control and visiting were generally effective. They noted a controlled drug discrepancy, a door that did not always close and lock, and incomplete records for some agency staff checks and induction.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found effective quality checks, regular monitoring and an open approach to reporting and learning from incidents. The manager had followed an action plan from the previous inspection.
What inspectors found, January 2023
Ponteland Manor Care Home was rated Good; inspectors found improvements in safety and management, but agency staff checks and consistency of care still need attention.
This was an unannounced focused inspection on 18 and 22 November 2022. Inspectors looked only at Safe and Well-led because concerns had been raised about managing a COVID-19 outbreak and earlier legal breaches.
Inspectors found that medicines, infection control, risk assessments, safeguarding and staffing levels were generally managed safely. However, records did not always show that the required checks and induction had been completed for agency staff. Agency use had also affected the consistency of care.
The home was rated Good overall, with Good ratings for Safe and Well-led. The other three ratings were carried forward from the previous inspection. The previous overall rating was Requires Improvement, so the overall rating improved after action was taken.
Improved safety systems
The home had improved its approach to risk assessments, medicines and infection control since the previous inspection. Inspectors found that people had received their medicines as prescribed.
“Systems were in place to ensure medicines were managed safely. Records confirmed people had received their medicines as prescribed.” from the report
Infection control
Inspectors were assured that the home had current infection control arrangements and could respond to infection risks and outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Safeguarding and choice
People and relatives said they felt safe. Inspectors found safeguarding systems and appropriate mental capacity arrangements in place.
“Systems were in place to protect people from the risk of abuse.” from the report
Management oversight
The manager used an action plan and daily checks to monitor quality and complete improvements. The report says the service was open and transparent.
“Effective governance systems were in place. A comprehensive action plan had been developed following our last inspection.” from the report
Agency staff checks
needs fixingRecords did not always prove that required checks or induction had been completed for agency staff. CQC recommended that the process and records be reviewed.
“Records were not available to demonstrate the appropriate checks or induction had always been completed for all agency staff who had worked at the home.” from the report
Consistency of care
needs fixingThe home relied heavily on agency staff because of recruitment difficulties. Inspectors said this had affected the consistency of care, although a recruitment campaign was expected to reduce agency use.
“Due to difficulties in recruiting permanent staff there had been a high use of agency staff. This had impacted on the consistency of care provided to people.” from the report
Medicines audit
needs fixingInspectors found a discrepancy involving one controlled drug that had not been identified by the medicines audit. The manager was told so it could be addressed.
“We identified a discrepancy with 1 controlled drug which had not been identified during the medicines audit.” from the report
Stairwell door
minorOne door leading to a stairwell did not always close and lock properly. Staff were alerted and immediate action was taken to make the area safe until it could be fixed.
“We did identify 1 door leading to a stairwell was not always closing and locking properly after use.” from the report
- 01What checks and induction are now completed and recorded before agency staff start work?
- 02How much is the home currently relying on agency staff, and what has happened with the planned recruitment campaign?
- 03How was the controlled drug discrepancy investigated, and what changes were made to medicines audits?
- 04Has the stairwell door been repaired, and how is its safety checked now?
- 05How will the home show that improvements from the previous inspection are being maintained?
This was a 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 5 January 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, June 2022
Ponteland Manor Care Home rated Requires Improvement; inspectors found caring staff but serious problems with medicines, infection control and management oversight.
This was an unannounced focused inspection after a coronavirus outbreak. Inspectors visited on 18, 22 and 23 February 2022. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was not always safe. Inspectors found problems with medicines storage and checks, risk assessments, COVID-19 testing, personal protective equipment and some visiting arrangements. Records of accidents and environmental checks were not always complete or reliable.
The home was also not always well-led. Audits had failed to identify some problems, some records had been completed retrospectively, and duty of candour procedures had not been followed. There were enough staff, people said they felt safe, and relatives spoke positively about the care and staff.
The overall rating changed from Good at the previous inspection, published in January 2020, to Requires Improvement. The provider was asked for an action plan, and the CQC said it would monitor progress and take further action if needed.
Enough staff
Inspectors found enough staff to meet people's needs and saw staff respond quickly.
“There were enough staff employed to meet people's needs. Throughout the inspection we saw staff responded to people quickly.” from the report
Kind care
People and relatives spoke positively about the staff and the care they received.
“The staff are very nice here, very caring and very helpful.” from the report
Safe recruitment
Recruitment records were well organised and the required suitability checks had been completed.
“Staff were recruited safely and recruitment records were well organised.” from the report
Action during inspection
The provider acted on some issues while inspectors were present, including moving vehicles and providing missing protective equipment.
“We brought this to the attention of the provider who took immediate action to ensure the necessary items were made available for staff.” from the report
Medicines
seriousMedicines were not always stored safely. Fridge temperatures were sometimes outside the normal range, unused medicines had not been returned, and there was a controlled-drug discrepancy.
“Numerous medicines required refrigeration and action had not been taken to ensure they were stored at the correct temperature or to confirm they remained safe to use.” from the report
Infection control
seriousCOVID-19 testing did not always follow guidance, and some staff did not use masks or follow bare-below-the-elbow requirements correctly.
“Staff did not always use PPE safely. We observed some staff not wearing face masks correctly and not following policies which specified staff should be 'bare below the elbow'.” from the report
Risk assessments
seriousSome risks were not properly assessed, including risks linked to equipment, parking and combustible items stored in a fire exit.
“The provider's failure to ensure all risks were assessed and monitored was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Management checks
seriousAudits did not identify all the problems found by inspectors. Some environmental records had been completed retrospectively rather than when checks were done.
“The failure of the provider to ensure accurate and contemporaneous records were kept and to ensure an effective governance system was in place was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Duty of candour
seriousThe home did not have an effective system to identify and deal with incidents that needed an open and honest response.
“The providers failure to ensure duty of candour policies and procedures were followed was breach of Regulation 20 (Duty of candour) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
- 01What has been done to make sure refrigerated medicines are kept at the correct temperature and unused medicines are returned to the pharmacy?
- 02How are you checking that risk assessments are in place for every person's health conditions, equipment and other identified risks?
- 03What changes have you made to COVID-19 testing, mask use and other infection prevention procedures?
- 04How do you now check that audits identify problems and that safety records are completed accurately at the time?
- 05What action plan did you send to the CQC, and what evidence can you show that the identified breaches have been corrected?
This began as a targeted inspection of infection prevention and control after a coronavirus outbreak, then widened to a focused inspection of Safe and Well-led; the other key questions were not rated. This explanation was written from the published report of 14 June 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 Ponteland Manor Care Home
5 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2020Goodstayed GoodSafe: GoodWell-led: Good
- June 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Inspected but not ratedSafe: Requires improvement
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 19 October 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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