The Care Quality Commission (CQC) has taken action to protect people living at Pinglenook Residential Home following an inspection in October that sees them rated inadequate again.
Pinglenook Residential Home provides accommodation and personal care to older people, some who may also be living with dementia.
The inspection was carried out to check if improvements had been made since the last inspection. Inspectors looked at the areas of safe, effective, and well-led at this inspection.
Following the inspection, the overall rating for the home is inadequate, as well as the areas of safe, effective, and well-led. The service was previously rated inadequate overall, and for being safe, effective, and well-led. Responsive and caring were previously rated requires improvement.
Craig Howarth, CQC deputy director of operations in the midlands, said:
“When we inspected Pinglenook Residential Home, we were disappointed to see that little improvement had been made since we last inspected. Leaders need to focus on making immediate improvements to ensure people receive safe and appropriate care.
“It was concerning that when people with complex needs required support, the provider failed to develop care plans to guide staff how to support them. This meant people were at risk of receiving unsafe care and signs of deterioration in their health condition may be missed.
“For example, someone living at the home experienced multiple episodes of distress and anxiety but there were no plans in place to support them or to record their triggers to ensure it didn’t happen again.
“In addition, records of fluid intake for people at risk of dehydration weren’t regularly completed which could place people at risk of dehydration or worsening health conditions. We also saw contradictory information in someone’s care plan who was at risk of choking on what modified foods they could eat which put them at risk of harm.
“However, some improvements had been made to environmental risks. The provider had completed a fire risk assessment at the service, and water temperatures were now within a safe range and were regularly monitored.
“We will continue to monitor the service closely to ensure the necessary improvements are made and people are kept safe during this time. If improvements are not made by the time we next inspect, we will not hesitate to take further enforcement action.”
Inspectors found:
- Systems and processes to ensure good oversight of the service were ineffective
- People's care wasn’t always personalised
- The provider didn’t ensure recruitment checks were carried out properly
- Infection prevention and control measures weren’t robust, and people were placed at risk of Legionella
- People were placed at risk of harm because of unsafe moving and handling practice
- Medicines weren’t managed safely which exposed people to the risk of harm
- The home environment didn’t reflect dementia friendly best practice to best meet people's needs.
However:
- Staff were positive about the training and support they received
- The provider understood their responsibilities in relation to the duty of candour and communication with people when things went wrong.
The report will be published on CQC’s website in the next few days.