Background to this inspection
Updated
3 November 2023
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 Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was carried out by 5 Inspectors, including a pharmacy Inspector.
Service and service type
Pinford End is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pinford End is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
Inspection activity took place between 14 September 2023 and 28 September 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. This included feedback from stakeholders and professionals who work with the service.
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
We used all this information to plan our inspection.
During the inspection
We used observation to gather evidence of people's experiences of the service. We spoke with 11 people who used the service and 6 relatives. We spoke with 16 members of staff including the registered manager, deputy manager, administrator, nurses, activities, care staff, cooks and the nominated individual and a company director. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a variety of records including 16 people’s care records, staff recruitment, incident reports, audits, medicines records, policies and procedures.
Updated
3 November 2023
About the service
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.