CQC report explained · a residential care home
What the CQC found at Pratt House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2021
Pratt House is rated Requires Improvement; inspectors found kind and effective care, but some risks were not managed and leadership checks were not always effective.
This was a focused inspection on 4 May 2021. Inspectors spoke with people, relatives, staff and professionals. They observed care and checked care plans, medicines, staff records, accident records and management audits.
People and relatives were positive about the care, staff and management. The home was clean, medicines were managed safely, staffing levels were sufficient, and people received support with health, food, activities and contact with relatives. The home also improved its environment and its person-centred care since the previous inspection.
Inspectors found important gaps in risk management. These included pressure wound care, fluid monitoring, choking, allergies and the risk of someone leaving the home unsupervised. They also found some problems with infection control arrangements and management audits. The overall rating stayed at Requires Improvement. Safe and well-led were Requires Improvement, while effective and responsive were Good.
Kind, respectful care
People and relatives said staff were kind and that people were kept clean, comfortable and engaged.
“I feel that the home offers a high standard of care and residents are kept clean, comfortable and entertained/engaged. I have only seen the staff acting kindly.” from the report
Staffing and continuity
Inspectors found sufficient staffing and a consistent staff team. People said staff were available when needed.
“I can always get someone's attention if I need it, there is always someone about and willing to help.” from the report
Improvement since the last inspection
The home improved in person-centred care, medicines, staff recruitment, the environment and governance. It was no longer in breach of Regulations 9, 17 and 19.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations 9, 17 and 19” from the report
Individual risks were not always managed
seriousSome care plans did not give enough guidance to reduce risks. Examples included a pressure wound, fluid intake, choking, allergies and leaving the home unsupervised.
“Risks to people were identified but these were not always managed.” from the report
Infection control gaps
needs fixingKitchen staff were not wearing masks and there were no exemptions or risk assessments. Communal furniture and signage did not promote social distancing.
“However, we were not fully assured that the provider was using PPE effectively and safely.” from the report
Audits missed safety problems
needs fixingThe home carried out regular audits, but these checks did not identify the risk management failures found by inspectors.
“However, the auditing system was not fully effective in relation to risk management, as outlined under the safe domain.” from the report
Apologies after incidents
minorThe manager was open about what happened, but letters of apology were not sent to people or relatives after two incidents as required by the home's policy.
“The registered manager told us they had telephoned the relatives and email updates were provided to them, but a letter of apology was not sent” from the report
End of life training
minorOnly nine of 28 staff involved in care had end of life training, and eight staff were overdue updates. The manager said further training was being sourced.
“Nine out of 28 staff involved in providing care were trained in end of life care” from the report
- 01What action has been taken to manage the risks around pressure wounds, fluid intake, choking, allergies and people leaving the home unsupervised?
- 02How are staff now following PPE and social distancing arrangements, and how is this checked?
- 03How have management audits been changed so that safety risks are identified and acted on promptly?
- 04How will the home follow the duty of candour process, including sending written apologies after relevant incidents?
- 05When will overdue end of life training updates be completed for staff?
This was a focused inspection of Safe, Effective, Responsive and Well-led, while Caring was not assessed and the report used the previous comprehensive inspection ratings where applicable. This explanation was written from the published report of 9 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, July 2019
Rated Requires Improvement; inspectors found kind care, but serious problems with risks, medicines, records and oversight.
This was an unannounced inspection on 26 and 27 June 2019. Inspectors spoke with seven people, six staff members and three relatives. They observed care and checked care, medicine, recruitment and management records.
People generally said staff were kind and caring. They felt their health and food needs were met, and they had activities and ways to raise concerns. However, staff vacancies meant people sometimes felt staff were stretched or did not respond quickly enough.
Inspectors found risks were not always properly assessed or controlled. Medicines were not always recorded safely, cleaning was inconsistent, and the building needed repair and refurbishment. Care plans were not sufficiently personal, information was not always accessible, and records and audits were not reliable.
The overall rating fell from Good at the previous inspection in 2016 to Requires Improvement. The service was not placed in special measures in this report. The provider was asked for an action plan, and CQC said it would monitor progress and return for a further inspection.
Kind relationships
People and relatives described staff as kind, caring, respectful and approachable. Inspectors also saw relaxed and positive interactions.
“People had positive relationships with staff. We observed people were relaxed and were seen to be laughing and joking with staff.” from the report
Choice and independence
People were offered choices about daily routines, food and activities. Staff supported people to do what they could for themselves and respected privacy.
“People were given choices in everyday decisions such as time to get up, go to bed, meals and activities.” from the report
Health and food support
People's health and nutritional needs were identified and supported. The home worked with health professionals and provided a varied diet.
“People were supported with their healthcare needs. They had access to a range of health care professionals” from the report
Activities and relationships
The home provided activities, outings and links with local groups. Some people felt the programme could offer more variety.
“Activities provided included bingo, exercises, manicures, arts and crafts, singers, entertainers, trips to local farms and a boat trip.” from the report
Risks and fire safety
seriousRisk assessments did not give enough detail about how to prevent harm. Inspectors found fire doors wedged open, clutter and other fire risks that had not been assessed.
“We found reasonable steps had not been taken to mitigate risks. This placed people at risk of harm.” from the report
Medicines
seriousA medicine trolley was left unattended with its key in. One person's time-specific Parkinson's medicine was not signed for on two occasions and this was not followed up.
“This placed people at risk of not getting their medicine as prescribed.” from the report
Cleanliness and building condition
needs fixingCleaning standards varied, with stained carpets, dirt, cobwebs, flies and an armchair that smelt of urine. The building also had worn carpets, damp patches and damaged surfaces.
“We found reasonable steps had not been taken to ensure the home was clean and hygienic.” from the report
Records and oversight
seriousAudits and checks did not reliably identify or resolve problems. Records included inaccurate rotas, incomplete charts, missing signatures and insecure files.
“We found reasonable steps had not been taken to effectively assess and monitor the service and to ensure records were fit for purpose.” from the report
Staffing pressure
needs fixingThere were three staff vacancies, covered by existing staff working extra hours. People said staff sometimes seemed rushed or did not respond when called.
“There has been occasions recently where the staff seem stretched and rushed” from the report
- 01What changes have been completed to make risk assessments more detailed, especially for epilepsy, falls, bed rails and fire safety?
- 02How are medicines now checked, including time-specific medicines and the security of the medicine trolley?
- 03What evidence can you show that staff recruitment checks, induction and training records are complete?
- 04How have care plans been rewritten to explain each person's specific preferences and support needs?
- 05What refurbishment and cleaning work has been completed, and how is it now checked?
This was an unannounced planned inspection covering all five CQC questions and both the care and premises; the previous overall rating was Good, published on 5 October 2016. This explanation was written from the published report of 30 July 2019 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 Pratt House
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- June 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 16 March 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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