Pinglenook Residential Home

Updated 25 March 2024

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

The inspection was carried out by 2 inspectors. An Expert by Experience also supported the inspection remotely by making telephone calls to relatives. 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

Pinglenook Residential Home 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. Pinglenook Residential Home is a care home without 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.

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 who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

Not everyone who lived at the home was able to share their views with us. As a result of this, we spent time observing interactions between people and the staff supporting them. We spoke with 2 people who used the service and 5 relatives about their experience of the care provided.

We spoke with 7 members of staff including the registered manager/nominated individual, manager, 4 care staff members, and cook. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We looked at a range of documents including people's care plans and risk assessments, staff recruitment records, training records, DoLS records and mental capacity assessments. We also reviewed audits and governance, medicines records and observed medicine administration. We conducted checks of the building, grounds, and equipment.

Updated 25 March 2024

About the service

Pinglenook Residential Home is a residential care home providing accommodation and personal care to up to 16 people. The service provides support to people aged 65 and over who may also be living with dementia. At the time of our inspection there were 12 people using the service.

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

People were not kept safe from known risks. Where risks were identified there was not always guidance to inform staff how to support people safely and consistently. Medicines were not managed safely which exposed people to the risk of harm. Infection prevention and control measures were not robust, and people were placed at risk of Legionella. The provider did not ensure recruitment checks were carried out in line with the regulations.

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. People's care was not always personalised. The home environment did not reflect dementia friendly best practice to best meet people's needs.

Systems and processes to ensure good oversight of the service were ineffective. People were at risk of receiving care that did not meet their needs or wishes. Records were either inaccurate or lacked detail to provide staff with guidance on how to support people appropriately. A robust system was not in place to ensure accidents and incidents were appropriately recorded and responded to.

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 inadequate (published 6 June 2023). This service has been rated inadequate for the last 4 consecutive inspections. At this inspection we found the provider remained in breach of regulations.

Why we inspected

This focused inspection was carried out to follow up on action we told the provider to take at the last inspection. This focused inspection was initially carried out to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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 Pinglenook Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to consent, safe care and treatment, protecting people from abuse, staff recruitment, person-centred care and governance at this inspection.

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

The overall rating for this service is ‘Inadequate’ and the service remains 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.