Pencombe Hall

Updated 11 September 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 was carried out by one inspector.

Service and service type

Pencombe Hall 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 apart from on the final day when we gave notice to complete and give initial feedback to the registered manager.

What we did before the inspection

Before the inspection we looked at the information we had received about the service since the last inspection. This included details about incidents the registered provider must notify us about, such as abuse and accidents. We sought feedback from the local authority who work with the service. We also requested feedback from Healthwatch to obtain their views of the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

We spent time with people in the communal areas of the home to see how staff supported people they card for. 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 spoke with six people who lived at the home and six relatives about their experiences of the care provided. We also spoke with a visiting healthcare professional.

We talked with the registered manager. In addition, we spoke with three staff members including team leaders, care staff and an agency member of staff.

We looked at a range of records. These included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service were reviewed.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found. The registered manager sent us the documents we requested in a timely way. We also spoke with the deputy manager and professionals from Herefordshire County Council on the telephone.

Updated 11 September 2019

About the service

Pencombe Hall is a care home providing accommodation and personal care for up to 32 people aged 65 and over in one large adapted building. At the time of the inspection 24 people were living at the home.

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

Further improvement from those made since our last inspection was found to be needed to ensure people always received a fully effective quality service.

The provider’s policies and procedures were not always followed. Quality audits had failed to identify areas of concern which could place people at risk of harm.

The meal time experience for people who required support from staff was found to need improvement as it did not take person-centred care into account.

Although the registered manager acknowledged these shortfalls and measures were put into place these shortfalls should have been identified earlier by the provider’s quality assurance systems.

People were cared for by staff who knew them well. People were supported by staff who understood safeguarding procedures and aware of people’s identified risks.

Sufficient staff were available to meet people’s needs. The registered manager was aware of the need to continually review staffing levels to ensure they were sufficient. People told us when they needed assistance, staff responded promptly so people’s safety needs were not compromised. Recruitment practices were in place to check the suitability of potential staff members.

People’s needs were assessed, and their care was planned and provided to meet people’s needs. Risk assessments were carried out regarding the care and support people required. People had a nutritious diet and they enjoyed the meals available. People’s healthcare needs were met by medical professionals involved in their care.

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.

People were cared for by staff were kind. Staff were considerate towards the people they cared for. People and relatives felt involved and supported in decision making. People’s privacy was respected, and their dignity maintained. People had fun and interesting things to do and occupy themselves with.

Rating at last inspection

The last rating for this service was requires improvement (published 23 July 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough, 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 two consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well led sections of this full report.

The provider took immediate action in relation to some areas of concern to mitigate risks to people using the service.

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

Enforcement

We have identified breaches in relation to the safe management of people’s medicines and monitoring the quality of the service provided at this inspection.

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

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.