142 Petts Hill Care Home

Updated 21 March 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

The inspection was carried out by one inspector.

Service and service type

142 Petts Hill Care 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. 142 Petts Hill Care 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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 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 met two people who used the service and observed interactions between them and the staff members. We spoke with two staff members, including the registered manager and the senior support worker.

We reviewed a range of records. This included all three people’s care records and their medicines records. We reviewed a variety of records relating to the management of the service, including policies and procedures and safety checks. We continued to seek clarification from the provider to validate evidence found. We also looked at training data and risk assessments.

Updated 21 March 2023

About the service

142 Petts Hill Care Home is a care home without nursing that provides accommodation, support and care for up to three people with mental health needs. At the time of our inspection, three people were living in the home.

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

Staff did not follow the provider’s procedure for recording and administration of medicines and we could not be assured people received their medicines safely and as prescribed. Similar issues were found at the last two inspections.

Risks to people's wellbeing and safety had not always been assessed. As in our previous inspection, one person admitted in April 2022 did not have a care plan or any risk assessments in place, and another person’s care plan had not been updated and did not reflect the care they were receiving.

Although there were risk assessments in place for another person, these were not always reviewed and updated regularly so risks were appropriately identified and mitigated.

The provider did not carry out regular safety checks including fire safety checks. The premises fire risk assessment had not been reviewed regularly. People’s emergency evacuation plans (PEEPS) were in place for one person, however, two people did not have these in place. This placed them at risk of harm should there be a fire or an emergency.

The provider’s infection control systems were not always effective. Some areas of the home were dusty and the fridge and some cupboards in the kitchen were unclean. There was no date of opening on food items. Some areas of the home were worn and needed updating and repairs were not always carried out in a timely manner.

People did not have access to meaningful activities and their care plans did not reflect what they liked doing or any interests they might have.

There were no records of any meetings with people who used the service and there was no evidence people were supported to feedback about the service.

The staff did not always communicate effectively with each other about the running of the service and there was little management oversight.

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.

The provider’s monitoring systems were not regular or effective and had failed to identify the shortfalls we found during the inspection. Furthermore, there was no evidence of lessons learned as issues we had found at previous inspections were repeated at this inspection.

The provider had processes in place for the recording and investigation of incidents and accidents. The registered manager told us there had not been any since our last inspection.

There were enough staff on duty at all times to meet people’s needs in a timely manner. Nobody had been recruited since the last inspection.

Staff had received training in safeguarding adults and demonstrated a good knowledge of this and what they would do if they thought someone was at risk of harm.

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 1 October 2021). 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. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We undertook the inspection to see if the provider had made improvements since the last inspection, and to find out how well the provider was meeting the key questions not inspected at our last two inspections.

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 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 breaches in relation to safe care and treatment, person-centred care, premises and equipment and good governance at this inspection.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. 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.