Archived: Pentlow Nursing Home

Updated 12 July 2019

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection team consisted of one inspector, a pharmacist inspector and an Expert-by-Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Pentlow 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 had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection because they had completed one in the last year. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We used all of this information to plan our inspection.

During the inspection

We spoke with 18 people who used the service and five relatives about their experience of the care provided. We spoke with 11 members of staff including the registered manager, clinical lead, quality manager, chef, activity staff, housekeepers, registered nurses and care staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. During the inspection we spoke to a health care professional who was visiting a person.

After the inspection

We spoke with a social care professional and two further health care professional who regularly visited the service.

Updated 12 July 2019

About the service

Pentlow Nursing Home is a residential care home providing personal and nursing care up to 60 older people. Accommodation and services are spread over two neighbouring buildings called Pentlow and Summerdown. At the time of the inspection 28 people were in Pentlow and 11 were in Summerdown. People's nursing and support needs varied, some were living with complex care needs and a dementia. Others had been admitted for short term placements from hospital or for emergency support, until they could return home or move to another service.

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

People were not always receiving their medicines safely or as prescribed. People were not always supported to have maximum choice and control of their lives and records did not demonstrate that staff had supported people in the least restrictive way possible and in their best interests. People did not always have their care needs recorded or attended to. Personalised care plans were not in place for everyone. Systems to asses, monitor and improve quality of the service had still not been established effectively in all areas. This meant areas that impacted on people’s safety and care had not been addressed.

The service was clean and hygienic. Staff had a good understanding of how to identify and respond to any suspicion or allegation of abuse or discrimination. Staffing arrangements ensured people’s needs were responded to in a timely way. Staff were recruited safely. There were suitable arrangements in place to assess and respond to risks to people and staff.

Staff training was co-ordinated and planned. All staff completed essential training to ensure they had suitable skills to care for people. Staff had the opportunity to develop new skills and maintain their competencies. People's dietary needs were assessed, and food provided was tailored to their individual needs.

People were supported by staff who were kind and caring. Staff promoted independence and ensured people spent time with and enjoyed time with people who were important to them. People felt comfortable with staff and formed positive relationships. Staff were aware of people’s privacy and dignity and made sure this was respected. People were listened to and had their choices responded to.

People were supported to take part in a variety of activities that they enjoyed and were meaningful. Complaints were responded to effectively. People’s communication needs were assessed and responded to. End of life care was planned and delivered in a compassionate way.

The registered manager had established an open and honest culture where staff and people felt able to share their views, and where incidents, safeguarding concerns and complaints were dealt with proactively.

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 17 December 2018) and there were two repeated breaches of regulations, a warning notice was served in respect of one breach. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, improvement had not been made and the provider was still in breach of regulations.

The service remains rated Requires Improvement. This service has been rated Requires Improvement for the last five consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to regulations 12, 11, 9 and 17. This is because medicines were not always handled safely. Staff were not working within the principles of the MCA. People’s needs were not fully recorded and responded to and the quality monitoring systems had not supported safe, effective and responsive care in all areas. Following the inspection, we received information from the registered manager and nominated individual. This confirmed action being taken and planned. It included the recruitment of a new deputy manager and new quality monitoring and governance systems.

Please see the action we have told the provider to take at the end of this report.