Archived: Pinford End House Nursing Home

Pinford End is a residential care home providing accommodation, personal and nursing care for up to 40 people across two floors. The service specialises in nursing care and support for people at the end of life. At the time of our inspection on day 1 there were 35 people using the service.

People’s experience of using this service and what we found

The provider’s governance systems and audit processes continued not to be robust enough to ensure shortfalls were identified and addressed. Actions the provider told us they would take following our last inspection had not been fully implemented.

The provider had failed to take action in response to fire safety concerns highlighted following external fire inspection visits. Fire safety procedures were unclear, and staff including agency nurses with overall responsibility for the safety of the building did not have access to the training and information they needed to respond in an emergency. This placed people at risk of harm.

The provider did not always respond to safeguarding concerns in line with their own policy and local protocols. Safeguarding processes were not fully effective, and concerns were not always the subject of sufficient scrutiny. This meant people were not protected from the risk of abuse.

Risks to people's health, safety and welfare were not managed effectively, placing them at significant risk. People's care records were not always person centred and accurate. They lacked information to guide staff in how to meet people's needs safely and effectively. When events or incidents had occurred, records did not evidence what action had been taken. There was no evidence lessons were learnt when things went wrong.

Infection control procedures were not always followed to ensure the spread of infection was reduced. Peoples' medicines were not managed safely. Checks for medical devices continued not to be carried out as required.

There were insufficient trained or supervised staff to safely meet the needs of people. People told us there was not always enough staff to meet their needs. Feedback from people using the service and their relatives was inconsistent and while we received some positive comments about the levels of support and quality of care, we also heard concerns about areas such as inadequate staffing, declining quality of food and the providers inadequate response to complaints.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We recommended the provider place appropriate accessible signage within the service to enable people living with dementia to orientate around the building. We also recommended the provider seeks guidance from an appropriate source to increase the use of accessible information to meet people's needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 February 2023).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received by the CQC about safe care and treatment, safeguarding, infection prevention and control, safe medicines management and good governance. We found evidence during this inspection that people were at risk of harm from these concerns.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people from abuse, safe care and treatment, medicines management, safeguarding, staffing, person-centred care and governance at this inspection.

We wrote to the provider during our inspection due to our serious concerns of people receiving poor quality care. We requested an urgent action plan. The provider told us they had not been aware of the significant failings at the service and risks posed to people's safety and well-being.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will also request an action plan from the provider to understand what they will do to improve the standards of quality and safety.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures.' This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

You can read the report from our last inspections, by selecting the 'all reports' link for Pinford End on our website at www.cqc.org.uk.

Pinford End is a residential care home providing accommodation, personal and nursing care for up to 40 people across two floors. The service specialises in nursing care and support for people at the end of life. At the time of our inspection there were 25 people using the service.

People’s experience of using this service and what we found

Governance systems were not robust enough to ensure shortfalls were identified and addressed. We found shortfalls in the management of risks to people's safety and welfare including, oversight of environmental risks, moving and handling plans, wound care and medicines management.

Audits in place had failed to identify the shortfalls we found at this inspection. These concerns had not been identified or resolved through current governance process.

The service was clean and well maintained. Further work was needed to ensure fire safety and equipment checks were carried out as required.

We received mixed views about the availability of staff at all times. We observed staff were visible and responding to call bells in a timely manner. Staff received training relevant to their roles and staff recruitment was carried out safely.

We observed positive relationships between people and staff. There was positive feedback from people and their relatives about staff kindness, approachability of management and good communication.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update The last rating under the previous provider was good (published 10 October 2018).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pinford End on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The service was clean, hygienic and free of unpleasant odours.

All staff had received recent training in infection control and prevention.

Personal protective equipment (PPE) stations had been created throughout the service. There were plentiful supplies of PPE and staff were observed wearing this appropriately.

There was signage throughout the service encouraging handwashing, the wearing of protective equipment (PPE).

Regular checks were in place to ensure effective infection prevention and control practices were followed.

Individual risk assessments had been conducted in consultation with staff and people who used the service.

Further information is in the detailed findings below.

Pinford End House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to accommodate up to 40 people who require nursing and/or personal care. At the time of the inspection 32 people were living at the home.

At our last inspection in January 2016 we rated the service good. The safe section of the report was rated as ‘requires improvement.’ This was because when people were prescribed medicines on a ‘when required’ basis, for example pain relief, or when they were prescribed variable doses, for example ‘one or two tablets’, we found that staff did not always record the number of tablets administered. This meant that it was not possible to conduct an accurate stock check of medicines. At this inspection we saw action had been taken to resolve this issue.

At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

People were helped to take their medicines by staff who were trained and had been assessed to be competent to administer medicines.

People were supported to be kept safe because the staff continued to follow relevant policies and had appropriate training. People’s risk assessments had been written and were reviewed regularly to minimise the potential risk of harm to people during the delivery of their care.

Staff wore protective clothing such as gloves and aprons when needed. This reduced the risk of cross infection.

People were looked after by enough qualified nursing and care staff, who were trained and supervised to support them with their individual needs. Staff were supported through supervision, training and an annual appraisal. Pre-employment checks were completed on new staff before they were assessed to be suitable to look after people who used the service.

The nursing and care needs of people were assessed prior to them coming to the service and those needs were reviewed on a regular basis and more frequently should that be deemed necessary. Care plans gave staff information on how to support people with their needs.

People had access to healthcare professionals and their healthcare needs had been met. Care records seen confirmed visits to and from General Practitioners (GP's) and other healthcare professionals had been recorded.

People continue to be offered choices and were supported to eat and drink sufficient amounts of food and drink and the ttaff knew the people they supported and provided support in a caring way that promoted their dignity.

Staff were able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People participated in a range of activities within the accommodation and also in the gardens of the service and received the support they needed to help them to do this. People’s concerns and complaints continued to be listened to and were acted upon.

The service was well led and provided strong leadership which promoted a positive, caring culture which was focused on the needs of people who used the service.

Quality monitoring procedures were in place and action was taken where improvements were identified. There were clear management arrangements in place. Staff, people and their relatives were able to make suggestions and actions were taken as a result.

Further information is in the detailed findings below.

We found that the service had taken action since our last inspection in February 2013 and they provided safe management of medicines.

We found that staff were well trained to meet the needs of people who used the service.

We found that people were treated with respect and consent was obtained before care and treatment commenced.

People told us that they experienced care, treatment and support that met their needs and protected their rights. Care plans were up to date and informative for staff to follow.

Staff told us they were well trained and were happy to work at this establishment. There were enough qualified, skilled and experienced staff to meet people's needs.

We found that people were put at potential risk because medicines were not always handled appropriately.