Pegasus Care Home received a 'Requires Improvement' rating following a focused inspection of Safe and Well-Led, driven by breaches of Regulation 12 (medicine management and risk assessment failures) and Regulation 17 (ineffective governance and audit systems). Strengths included low staff turnover, responsive leadership, robust safeguarding practice, and adherence to MCA principles.
Concerns (7)
criticalMedication management: “when we checked the stock balance of medicines these were not always accurate with what had been administered. There were a lack of records stating what the overall stock balance should be.”
criticalGovernance: “medicines audits were ineffective as they did not identify stock count inaccuracies. Kitchen audits and cleaning schedules did not identify rust in the microwave.”
moderateMedication management: “some topical creams and liquid medicines had not been dated when they were opened. This meant there was a risk these could be used after their expiry date.”
moderateCare planning: “care plans did not always contain accurate information about people's risks...some risk assessments lacked detail about what special equipment people needed or how staff should monitor”
moderateCare planning: “some of these were not always person centred. Some people's care plans did not contain detailed information about their goals, aspirations, and development of life skills.”
moderateRecord keeping: “Some of the daily records did not always clearly detail what de-escalation methods were used before medication and other interventions were used.”
minorInfection control: “some areas of the care home and some supported living houses where the integrity was compromised due to wear and tear. This would impact the providers ability to prevent infections.”
Strengths
· Staff had low turnover, supporting consistent care from staff who knew people well.
· Safeguarding procedures were followed and lessons learnt following concerns about unexplained bruising.
· Staff understood how to recognise and report abuse and knew how to apply training.
· People were supported to have maximum choice and control in the least restrictive way; MCA and DoLS principles were followed.
· The registered manager was open, transparent, and responsive to inspection feedback, taking prompt remedial action.
Pegasus Care Home was rated Good overall across four of the five key questions, with staff described as caring and people supported to live independently and access their community. Well-led was rated Requires Improvement due to ineffective audit processes, failure to conduct ongoing medicines competency checks, and inconsistent quality monitoring.
Concerns (5)
moderateMedication management: “We saw no evidence that medicines checks were being carried out to ensure the management arrangements for medicines were sufficient or that staff competency was being checked.”
moderateStaff competency: “I have not had my competency checked since... Another member of the staff told us they had not had their competency checked in over 12 months.”
moderateGovernance: “Cleaning rotas were not being regularly monitored and checked and as a result we saw areas of the home which had not been regularly dusted and cobwebs had gathered.”
minorStaffing levels: “Over a weekend when more people were in the home due to the respite service there was no indication that staffing levels were being adjusted based upon people's needs.”
minorStaff training: “It was clear that while training was available not all staff had completed the MCA training and DoLS training was in the process of being delivered.”
Strengths
· People told us they felt safe and were happy with how staff administered their medicines
· Staff demonstrated a good understanding of people's needs, likes and dislikes
· People's independence, privacy and dignity was respected by staff
· People were supported to access healthcare professionals and community activities
· Robust recruitment process including DBS checks, references, and shadowing induction
Pegasus Care Home was rated Good across all five key questions at this March 2019 inspection, providing personal and nursing care to eight residential and 15 supported living people with learning disabilities. No regulatory breaches were identified; previous governance concerns from 2015 had been fully addressed by this inspection.
Strengths
· People were safe from harm and abuse; staff could recognise and report safeguarding concerns
· Medicines were administered accurately, on time, and stored safely with adequate stock checks
· Sufficient staffing levels maintained in both residential and supported living settings
· Staff received regular induction, training updates, supervision and appraisals
· Care plans were person-centred, regularly updated, and reflected people's preferences, culture, religion and diversity
Quality-Statement breakdown (24)
safe: Supporting people to stay safe from harm and abuse, systems and processesGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Staffing levelsGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff skills, knowledge and experienceGood
effective: Supporting people to eat and drink enough with choice in a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supportedGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Planning and promoting person-centred, high-quality care and support; and how the provider understands and acts on duty of candour responsibilityGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood