CQC report explained · a residential care home
What the CQC found at The Pleasance
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found thorough care plans, suitable risk assessments, secure premises, sufficient staff, improved safeguarding systems, safe medicines arrangements and suitable infection control.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found better leadership, organised and up-to-date records, improved oversight, clearer staff roles and evidence that incidents were analysed to support learning.
What inspectors found, July 2023
Rated Good and no longer in special measures; inspectors found safer, well-managed care after major improvements.
This was an unannounced focused inspection on 13 and 15 June 2023. Inspectors spoke with 11 people who lived at the home and 10 staff. They reviewed care files, staff files, medicines records, audits and other management records.
The home was rated Good for Safe and Well-led. Inspectors found that care plans and risk assessments had improved, the premises were secure and clean, staffing and training had improved, and safeguarding and medicines systems were working safely.
The home had been rated Inadequate at the previous inspection in December 2022 and had been in special measures. Inspectors found the required improvements had been made, the home was no longer in breach of regulations, and it was no longer in special measures.
Better risk management
Care plans and risk assessments were thorough and reviewed appropriately. Staff understood how to reduce risks, and the premises were made more secure.
“Care plans were thorough and detailed. A range of risks were assessed and reviewed appropriately.” from the report
Staffing and training
Inspectors found enough staff to meet people's needs. Recruitment checks and mandatory training were in place, including training specific to epilepsy and rescue medication.
“There were sufficient staff on duty to keep people safe, meet their needs and provide them with support.” from the report
Improved oversight
Management and governance systems had improved. Records were accurate and up to date, and incidents were reviewed for learning and improvement.
“Information about the management, review and oversight of the service was well organised, accurate and up to date.” from the report
No registered manager at the visit
minorThere was no registered manager in post when inspectors visited. A new manager had applied to register and the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Has the new manager now been registered, and who is responsible for the home until that happens?
- 02How will you keep the improvements from the action plan under review?
- 03How much agency staff is currently being used, following concerns identified about agency staff?
- 04How are incidents, including their triggers and locations, reviewed and used to change care?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 5 July 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, May 2023
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, staffing, safeguarding and management.
Inspectors visited the home without notice on 13 and 14 December 2022. They spoke with people, relatives and staff, and checked care files, staff records, medicines records, audits and incident records.
They found people were at risk because known risks were not always assessed or reduced. Some people did not receive the one-to-one support they needed. Incidents, safeguarding concerns and some reportable events were not consistently recorded or shared with the right authorities.
There were also problems with staff training, building security, cleanliness and infection control. Inspectors found that the management checks had not identified or fixed these problems. The home was rated Inadequate for Safe and Well-led, and the overall rating fell from Good in 2018.
The provider took some action after the inspection, including updating risk assessments, strengthening security and introducing technology to help monitor epilepsy at night. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months.
Medicines
Inspectors found that people received the correct medicines at the right time. Records, storage and stock checks gave inspectors assurance that medicines had been administered as recorded.
“People received the correct medicines at the right time.” from the report
Mental capacity safeguards
The home was working within the Mental Capacity Act. Where people were deprived of their liberty, the report says the necessary authorisations and conditions were in place.
“We found the service was working within the principles of the MCA” from the report
Kind interactions
Staff were described as warm and respectful in their interactions with people. People and relatives also told inspectors they were happy or satisfied with the care.
“Staff interacted with people with warmth and respect.” from the report
Person-centred activities
People were supported to take part in activities they enjoyed and to maintain links with the local community.
“Person centred care was promoted, and people were supported to take part in activities which they enjoyed” from the report
People left without required support
seriousStaff were not always deployed safely. Some people were left without agreed one-to-one support, including an incident where a person choked on food.
“Staff were not always effectively deployed to meet people's needs.” from the report
Risks were not controlled
seriousKnown risks were not consistently assessed, reviewed or reduced. This included risks relating to fire, public safety, the environment and epilepsy at night.
“People were at significant risk of harm as known risks had not been adequately assessed and reduced.” from the report
Safeguarding and incident reporting
seriousSome safeguarding concerns and incidents were not recognised, recorded or reported to the police, local authority or CQC when required.
“Safeguarding systems and processes were not robust to ensure people were always protected from the risk of abuse.” from the report
Staff training
needs fixingTraining for medicines given using specialised techniques was not updated annually or signed off by a healthcare professional as required by the home's policy.
“Staff training for medicines administered by specialised techniques had not been updated annually” from the report
Cleanliness and infection control
needs fixingStaff did not consistently wear face coverings correctly during a recent COVID-19 outbreak. Some areas needed deep cleaning and some flooring created an infection hazard.
“The service was not clean.” from the report
Weak management checks
seriousThe provider's audits and quality checks failed to identify several serious problems. This meant risks were not always addressed promptly.
“The registered manager and provider had failed to ensure the quality assurance systems were reliable, robust and effective to drive improvements.” from the report
- 01What changes have you made to ensure every person receives their agreed one-to-one support, including during domestic tasks and meals?
- 02How are you now assessing and monitoring fire, public safety, environmental and night-time epilepsy risks?
- 03How do you make sure all safeguarding concerns and reportable incidents are recognised, recorded and reported promptly to the police, local authority and CQC?
- 04What evidence can you show that staff have completed and had their specialist medicines training competency signed off?
- 05What improvements have been made to cleanliness, face-mask use, flooring and building security since this inspection?
This inspection rated Safe and Well-led only; the report does not give current ratings for Effective, Caring or Responsive. This explanation was written from the published report of 11 May 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.
Every inspection of The Pleasance
4 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2023Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- May 2018Goodstayed GoodSafe: GoodWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2014
Report published without a new overall rating.
- March 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.
- August 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 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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92 live-in carers within about an hour of Doncaster
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 77 can care for a couple. 11 years' experience on average.
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“I can honestly say without Petros I don't believe he would have lived an extra 2 years”
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