CQC report explained · a residential care home
What the CQC found at Promenade Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments were missing or not detailed enough, accident and incident processes were not always effective, and medicines records had missing signatures and other gaps. The home was clean, staff numbers observed were sufficient, and recruitment checks were completed.
- Effective?
- Requires improvement
- Food and drink records and some care plans did not accurately reflect people's needs. Staff were trained, knew people well, and sought health advice when needed.
- Caring?
- Good
- This key question was not inspected during this focused inspection.
- Responsive?
- Good
- This key question was not inspected during this focused inspection.
- Well-led?
- Requires improvement
- Governance and monitoring systems did not identify all the problems found by inspectors, including safeguarding and incident reporting gaps. The manager was described as approachable and staff felt respected, valued and supported.
What inspectors found, August 2023
Promenade Care Home was rated Requires Improvement; inspectors found risks, safeguarding, medicines and records needed urgent improvement.
This was a focused inspection after concerns about a person's skin condition. Inspectors visited on 21 and 26 June 2023, spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment and management records.
The home was not always safe. Risk assessments were missing or lacked detail, some incident records were poor, and safeguarding concerns were not always properly investigated or referred. Medicines records also had missing signatures and other gaps.
The home was not always effective or well-led. Food and drink records did not always reflect people's needs, and monitoring systems had missed important problems. The provider took immediate action during and after the inspection, but CQC found three legal breaches.
The overall rating fell from Good at the previous inspection to Requires Improvement. This inspection covered Safe, Effective and Well-led only. Caring and Responsive were not inspected, so their previous ratings were used in the overall rating calculation.
Staff knew people well
Staff were described as skilled and attentive. Inspectors found that staff could recognise changes in people's health and escalate concerns.
“Our conversations with staff demonstrated they were skilled and knew people well.” from the report
Immediate action
The provider and manager responded to the inspection concerns and updated care plans, safety arrangements and monitoring processes.
“The provider and manager were receptive to the concerns found during the inspection and took immediate and robust action to reduce the risk of harm to people living at the home.” from the report
Clean environment
Inspectors found the home clean and hygienic. People and relatives spoke positively about the cleanliness.
“The home was clean and hygienic throughout.” from the report
Health concerns escalated
Staff sought advice from health professionals when they noticed concerns, including changes in blood glucose levels.
“There were effective systems in place for staff to escalate any concerns they had about people's health.” from the report
Supportive management
The manager was approachable, consistent and visible. Staff said they felt respected, valued and supported.
“The registered manager was approachable, consistent, and visible.” from the report
Risk assessments
seriousSome risks to health and safety were not assessed or recorded well enough to guide staff. Inspectors also found that security was not robust enough where people were at risk of leaving unassisted.
“Risk assessments were either not completed or not detailed enough to guide staff on how to safely support people” from the report
Safeguarding oversight
seriousThe manager did not have oversight of all safeguarding incidents. Some concerns were not investigated or referred to the safeguarding authority when required.
“The registered manager did not have oversight of all safeguarding incidents and therefore, appropriate investigation and referral to the safeguarding authority had not always taken place.” from the report
Medicines records
seriousPeople received their medicines as prescribed, but records were not always completed properly. There were missing signatures, missing guidance for some as-needed medicines, and no records for some thickening agents added to drinks.
“Medicines administration records (MAR) were not always completed in line with best practice guidance, and we found missing signatures on multiple records.” from the report
Food and drink records
seriousRecords did not always show people's nutritional and fluid needs accurately. This included a case where a recommended restricted fluid intake was not shown as being followed.
“Records did not demonstrate the recommended intake was followed for a person who had a restricted fluid intake in place due to a health condition.” from the report
Management checks
needs fixingQuality checks failed to find all the problems identified by inspectors. This meant opportunities to improve safety were missed.
“Monitoring systems had failed to identify all shortfalls found during the inspection process with risk management, accident and incident processes and safeguarding.” from the report
- 01What changes have been made to risk assessments for skin conditions, diabetes, food and drink, and people at risk of leaving the home?
- 02How are all safeguarding incidents now recorded, reviewed, investigated and referred to the local authority when needed?
- 03How does the home check that medicines administration records are complete, including as-needed medicines and thickening agents?
- 04How are food and drink records checked against each person's nutritional and fluid requirements?
- 05What action plan was submitted to CQC, and what evidence can you show that the improvements are being maintained?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried over into the overall rating calculation. This explanation was written from the published report of 1 August 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, December 2017
Promenade Care Home remained Rated Good; inspectors found safe, kind and personalised care, with some records needing improvement.
This was an unannounced inspection over 31 October and 1 November 2017. Inspectors reviewed care records, medicines, staff files, training, complaints, accidents, audits and other management records. They also spoke with people living at the home, visitors and staff, and observed the home.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found person-centred care, suitable staffing, safe medicines, trained staff and a friendly atmosphere. People and relatives were generally positive about the care and leadership.
Inspectors found some areas where records could be stronger. Information about medicines given when needed was limited, recording of thickening agents needed to be more accurate, and mental capacity assessments needed more detail. The home acted on these points during or after the inspection.
Kind and respectful staff
Inspectors saw staff provide care in a kind, compassionate and respectful way. People and relatives also spoke positively about staff.
“During the inspection we observed staff provided care and support to people in a kind, compassionate, respectful and sensitive manner.” from the report
Activities and social life
The home offered daily activities, trips out and events. People said they enjoyed the programme and did not feel lonely.
“We saw that the activities coordinators provided an extensive activities programme some of which were specifically for men which had been well received.” from the report
Listening to feedback
The home gathered views through meetings and questionnaires and acted on suggestions. Changes included menus, shift patterns and the key worker role.
“The information from satisfaction questionnaires and meetings was used to make positive changes and these had been acted on promptly to help improve the service.” from the report
As-needed medicines records
needs fixingCare plans had limited information about medicines given only when needed, such as pain relief. The registered manager was told and protocols were drawn up immediately.
“People using the service had a care plan which made reference to their medicines though there was limited information around the use of 'as and when' required (PRN) medication.” from the report
Mental capacity records
needs fixingMental capacity assessments were in place, but inspectors asked for more detailed recording to support decisions made for people who could not make particular decisions themselves.
“The registered manager said they would review how people's mental capacity was assessed to ensure this was recorded in more detail to support the decisions made.” from the report
- 01How are medicines given only when needed recorded now, and how do staff decide when they should be given?
- 02How do you record the use of thickening agents in drinks and check that this is done accurately?
- 03What changes have been made to mental capacity assessments since the inspection?
- 04How are people's religious food preferences identified and provided for?
- 05How have changes to early morning staffing and the key worker role affected continuity of care?
This was an unannounced inspection of the overall service, covering all five CQC questions, and the report says all ratings remained Good from the previous inspection. This explanation was written from the published report of 5 December 2017 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 Promenade Care Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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