2 November 2022
During an inspection looking at part of the service
Pen Inney is a residential care home providing personal care to up to 20 people. The service provides support to older people. At the time of our inspection there were 18 people using the service.
The service is on 2 floors with access to the upper floor via stairs or a stair lift. Some rooms have en-suite facilities and there are shared bathrooms, shower facilities and toilets. Shared living areas include a lounge, dining room, garden and patio seating area.
People’s experience of using this service and what we found
People were not 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.
There were gaps in monitoring systems. For example, some people living at Pen Inney House were unable to make decisions in relation to their care and support due to their health. Restrictions had been put in place to keep people safe. Records to demonstrate the restrictions were in line with legislation had been archived and the restrictive practices were not being monitored. The manager assured us they would audit the restrictive practices in place and take steps to ensure these were reasonable, proportionate and in people’s best interest.
Checks on fire equipment were carried out, however, the records to evidence these checks had taken place were not always completed. The records indicated a fault in equipment had been identified. It was not clear if any action had been taken to rectify this.
There were no systems in place for gathering feedback from people living at Pen Inney House, or their families.
Other audits had been completed, for example medicine administration records and accident and incident forms were checked regularly to identify any areas for improvement.
Risks were identified and recorded. Risk assessments and guidance for staff on how to minimise risks were not always available and we have made a recommendation about this in the report.
People told us they felt safe living at the service and they trusted staff and considered them skilled and competent. Training records showed staff training was up to date.
Pen Inney House was located in a rural village and there were strong links with the local community. Areas of the building were in need of updating and this was being planned. People’s bedrooms were spacious. When identified as necessary, alterations had been made to ensure the environment met people’s needs.
Staff told us they were well supported. They received regular supervision and the manager frequently worked alongside staff which allowed them to monitor staff skills and values. Staff told us morale was good and they had a shared set of values. They knew people well and understood their needs and preferences.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 24 April 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. 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 effective 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 Pen Inney House on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified a breach in relation to the oversight of the service
Please see the action we have told the provider to take at the end of this report.
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.