CQC report explained · a residential care home, run by Promoting Active Support
Our House
South Petherwin, Launceston, PL15 7LQ
Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found serious safety, staffing and management failings, and issued a warning notice.
This was an unannounced focused inspection by two inspectors on 27 November and 4 December 2023. They examined Safe, Effective and Well-led because of concerns about medicines, staffing, training, safeguarding and management oversight. They spoke with people, staff, relatives and professionals, and checked care, medicine, recruitment, training and management records.
The home was not always safe. Inspectors found unresolved fire, electrical, gas and water safety issues, dirty and cold areas, trip hazards, incomplete risk assessments and inaccurate medicines records. Staffing was also short, recruitment checks were incomplete and some staff had not completed enough training.
There were positive findings. People were supported by staff who understood their needs and communication, people could make choices, and staff helped people access healthcare. The provider acted on some issues during the inspection, including cleaning the home, making it warmer and developing additional risk assessments.
The overall rating fell from Good at the previous inspection, published on 1 April 2020, to Requires Improvement. The home breached four regulations. CQC will request an action plan and monitor progress with the provider and local authority.
Staff understood people
Staff understood people's individual needs and communication preferences. People approached staff for help without hesitation.
“People approached staff for support without hesitation and staff responded positively to people's requests.” from the report
Choice and consent
People were supported to make choices and were offered support and consent before assistance was provided.
“People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.” from the report
Healthcare support
Staff worked with healthcare professionals and helped people access healthcare when needed.
“People had been supported to access health care services when needed.” from the report
Action during inspection
The provider responded to feedback by cleaning the home, making it warmer and adding risk assessments.
“By the second day of the inspection the service had been cleaned, was noticeably warmer and additional risk assessments had been developed.” from the report
Premises and fire safety
seriousInspectors found unresolved fire service recommendations, wedged-open fire doors, damaged flooring and other safety issues. The home was also dirty and cold on the first inspection day.
“Fire doors were propped open with wedges, and flooring was in need of replacement and presented trip hazards in the service's communal spaces.” from the report
Risks were not managed
seriousSpecific risks linked to people's behaviours and one person's ingestion of non-food materials had not been assessed or properly reduced before the inspection.
“The provider failed to ensure risks in relation to people's known care and support needs were adequately mitigated.” from the report
Staffing and training
seriousThere were repeated periods with only three daytime staff, night shifts were sometimes covered by day staff sleeping in, and a third of staff had completed less than half of the required training.
“The reduced staffing levels at Our House were restricting people's opportunities to leave the service and access the community.” from the report
Recruitment checks
seriousSome necessary checks had not been completed. There was no recruitment information for one person and robust references were not recorded for two recently recruited staff.
“The provider had not completed necessary pre-employment checks.” from the report
Medicines records
needs fixingMedicine administration records were not consistently signed or accurately completed. Records about one varying-dose medicine contradicted each other.
“Medicine Administration Records (MARs) had not been consistently completed, staff had not always signed the MAR to show medicines had been administered as prescribed.” from the report
Weak oversight and privacy
needs fixingThe provider's audits had not picked up important safety and premises problems. Inspectors also found that privacy and dignity were not always respected.
“The provider's quality assurance systems were not sufficiently robust.” from the report
- 01Which fire safety, electrical, gas, water and flooring problems identified in the report have now been fully fixed, and can you show us the latest safety records?
- 02How many staff are normally on duty during the day and at night, and how do you make sure people can go out when they wish?
- 03What recruitment checks have now been completed for every staff member?
- 04What proportion of staff have completed the training needed for the people living here, and how are new staff prioritised for training?
- 05How are medicines administration records checked now, including records for medicines given in varying amounts?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 29 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Our House
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2020Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Registered with the Care Quality Commission on 6 February 2015.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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Other services run by Promoting Active Support Limited
1 other service on the CQC register. A pattern across a group tells you more than one report.