Pennington Court Nursing Home was rated Requires Improvement overall following an unannounced focused inspection in May–June 2023, with breaches of Regulations 11, 12, and 17 identified relating to consent, unsafe medicines management, and ineffective governance. The service had remained at Requires Improvement since its previous inspection in September 2021, with ongoing failures in care planning, record keeping, and quality assurance, offset by assured infection control and positive safeguarding practices.
Concerns (8)
criticalMedication management: “Medicines were not received, stored, administered, and disposed of safely...Fridge temps were not within correct limits. Some medication stock checks were incorrect on day of inspection.”
criticalConsent / capacity: “One person had a bed/chair sensor in place no mental capacity or best interest decision was recorded and this was not referenced within the persons care plans or risk assessments.”
criticalGovernance: “Quality assurance processes had not identified all the areas which needed to improve...issues we found with record keeping and fire safety had not been identified by the provider.”
moderateRecord keeping: “Care intervention records were not always recorded contemporaneously...records relating to pressure area care, cream applications and pad changes for several people were incomplete.”
moderateCare planning: “Care plans lacked personal information and guidance, and some contained contradictory information...one person had no sheet on her bed or duvet...this was not reflected within the persons support plan.”
moderateIncident learning: “Within one person care records there was evidence of three incidents, however only one of these was evidenced on an accident and incident form.”
moderatePerson-centred care: “One person said, 'I am very happy here, but I haven't been involved in my care plan.' Their relative...also confirmed that they had not been involved.”
minorCommunication with families: “Some relatives would have welcomed more communication in relation to appointments. Not everyone knew the registered manager.”
Strengths
· Infection prevention and control measures were assured across all domains including PPE use, admission processes, and outbreak management.
· Safe recruitment procedures were in place.
· Staff had received safeguarding training and knew how to report concerns.
· People and relatives felt safe; one person said 'I feel safe because I get everything I want; the staff are cheerful.'
· Staff involved in medicines handling had received recent training and had competencies assessed.
Quality-Statement breakdown (17)
safe: Using medicines safelyRequires improvement
safe: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
responsive: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Continuous learning and improving care; quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
Pennington Court Nursing Home deteriorated from Outstanding to Requires Improvement, with breaches of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) identified across infection control, record keeping, care planning, and complaints handling. Governance and quality assurance processes failed to identify or address key risks, though medicines management, staff stability, and proactive health monitoring were noted as strengths.
Concerns (10)
criticalInfection control: “The provider was not ensuring all staff were following the latest government guidance in terms of PPE, in particular the wearing of the correct type of face masks.”
criticalRecord keeping: “Records relating to pressure area care, cream applications and pad changes for several people were incomplete...there were gaps in people's records.”
criticalGovernance: “Quality assurance processes had not identified all the areas which needed to improve...issues we found with record keeping and infection control had not been identified by the provider.”
criticalSafeguarding: “A relative told us of a recent incident which had been reported to the home...the registered manager advised they had not been informed of this incident.”
moderateCare planning: “Some areas of the care plans we looked at were not sufficiently personalised and contained contradictory information.”
moderateIncident learning: “The recording of incidents was inconsistent and there wasn't always a clear analysis of the event to ensure lessons were learnt and shared with staff.”
moderateComplaints handling: “The provider was not recording informal complaints such as a relative complaint about their relation wearing clothes that did not belong to them.”
moderateConsent / capacity: “There was a lack of decision specific capacity assessments and best interest decisions balancing the benefits and burdens of each specific decision.”
moderateEnd-of-life care: “Advanced care plans were not sufficiently detailed. We were shown a blank document for people in the last few days of life which once completed fully would provide the necessary details.”
moderateStaffing levels: “There were no agency staff profiles for temporary staff who were on duty during this inspection...the provider was unable to evidence how they had assured themselves in relation to the training and competency of these staff.”
Strengths
· Medicines were managed safely; staff handling medicines had received recent training and had competencies assessed.
· People and relatives reported feeling safe, with most expressing satisfaction with the care provided.
· The service was proactive in recognising changing health needs and referring to relevant health professionals.
· Staff demonstrated low turnover and high job satisfaction, contributing to a stable workforce.
· The provider supported staff wellbeing throughout the pandemic with fortnightly packages and counselling sessions.