CQC report explained · a nursing home
What the CQC found at Pear Tree Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2021
Rated Requires Improvement; inspectors found unsafe risk and medicines management, and weaknesses in records and leadership.
This was a focused inspection on 15 December 2020. Inspectors looked mainly at whether people were safe and whether the home was well-led. They spoke with people, relatives and staff, observed care, checked the environment and reviewed care, medicines and management records.
Inspectors found that risks were not always assessed or managed safely. Records about falls, choking, weight loss, food and fluids, and repositioning were incomplete or inconsistent. Medicines were not always managed safely, including controlled drugs, storage and records for skin creams. Staffing levels received mixed feedback, although inspectors observed enough staff during the visit and the staffing tool showed the home was staffed above its calculated requirement.
The home had systems for safeguarding, infection control and learning from incidents, and improvements were already being made. However, quality checks had not found all the problems. Inspectors also found inconsistent leadership, limited feedback from people and relatives, and some disrespectful staff interactions. The overall rating fell from Good at the previous inspection to Requires Improvement.
Safeguarding awareness
Staff understood their safeguarding responsibilities, and the manager understood what action was required. The provider had also taken action after concerns were raised by the local authority safeguarding team.
“Staff we spoke with understood their responsibilities to safeguard people and how to report their concerns.” from the report
Staffing checks
Although people and staff gave mixed views about staffing, inspectors observed enough staff to meet people's needs. The provider was reviewing how staff were deployed.
“The provider used a dependency tool to calculate the number of staff required to meet people needs.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection outbreaks, testing, admissions and hygiene.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Some medicines improvements
Medicines were administered by trained and assessed staff, and records showing prescribed medicines had been given were complete. Audits showed medication errors had reduced substantially.
“Medication audits showed improvements had been made and medication errors had decreased substantially.” from the report
Risk records and prevention
seriousRisk assessments and care plans were not always complete, accurate or consistent. Inspectors found examples involving falls, choking, weight loss, food and fluids, and repositioning.
“Information about risks and actions to mitigate such risks to people was not always consistent in people's care records.” from the report
Medicines management
seriousThere were errors in controlled-drug records, medicines were not always dated when opened, and records for skin creams were incomplete. This was a breach of Regulation 12.
“The failure to ensure the proper and safe management of medicines was a breach of Regulation 12 (Safe care and treatment)” from the report
Governance and records
seriousQuality systems had not identified all the problems found by inspectors. Records were not always accurate or complete, which was a breach of Regulation 17.
“The failure to ensure effective systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and others” from the report
Leadership and culture
needs fixingLeadership had changed and people and relatives were unclear who was managing the home. Inspectors also found difficulties in creating a positive staff culture and made a recommendation about this.
“People and relatives were not clear about who was managing the service.” from the report
Respectful care
needs fixingInspectors saw two occasions where staff did not treat people respectfully. The manager acted immediately after this was raised.
“We observed people were not always treated respectfully by staff.” from the report
Limited feedback
needs fixingThere was limited evidence that the views of people, relatives and staff were collected and used to improve the home.
“We did not receive any evidence that feedback about the service had been collected from people and relatives and analysed to identify improvements.” from the report
- 01What has been done to make sure falls, choking, weight loss, food and fluid intake, and repositioning risks are assessed and recorded consistently?
- 02How are controlled drugs, opened liquid and topical medicines, medicines for disposal, and cream application records now checked?
- 03What evidence can you show that the new manager's action plan has been completed and that the changes are working?
- 04How do you make sure staff treat people respectfully and that concerns about staff behaviour are acted on?
- 05How are people, relatives and staff now asked for their views, and how are those views used to make improvements?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from previous comprehensive inspections. This explanation was written from the published report of 8 April 2021 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.
What inspectors found, May 2019
Rated Good overall, but inspectors found training, supervision and some mental capacity decisions needed improvement.
This was an unannounced planned inspection on 27 and 28 February 2019. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care records, medicines records, staff files, rotas, complaints and quality checks.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Inspectors found people were safely cared for, treated kindly and supported with personalised care. The building was clean, well maintained and designed to support people living with dementia.
Effective was rated Requires Improvement. Twenty-four staff had not had their induction signed off. Some required training was incomplete and records of staff supervision were not available. Inspectors also found that some decisions for people who lacked mental capacity were not clearly assessed or recorded.
Staff availability was sometimes stretched, particularly for people with more complex nursing needs. This affected preferred times for getting up, responses to personal care and access to activities. The provider had begun making changes, including recruiting activity staff and reviewing staff deployment.
Safe care
Inspectors found that risks were assessed and staff knew how to support people safely. Medicines were administered, recorded, stored and disposed of safely.
“People were safe and protected from avoidable harm. Legal requirements were met.” from the report
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff asking permission, respecting privacy and helping people make choices.
“Our observations of staff interactions with people showed that people were mostly treated with kindness, compassion, dignity and respect.” from the report
Personalised care
Care plans included people's needs, preferences and communication needs. Staff used this information to provide care suited to each person.
“People had detailed and person-centred care plans in place” from the report
Dementia-friendly environment
The home had areas and objects designed to support people living with dementia. It also offered different spaces, activities and outside areas.
“The environment for people living with dementia had been carefully designed to be both stimulating and comfortable.” from the report
Learning from incidents
The home reviewed accidents and incidents and used the information to improve how staff supported people.
“Records showed that an analysis of incidents had been carried out so that staff could learn how to support people more effectively and safely.” from the report
Training and supervision
needs fixingSome staff had overdue induction sign-offs, and required moving and handling and fire safety training was incomplete. The home could not show how often all staff received supervision.
“24 staff had not had their induction signed off to confirm they were competent to provide care” from the report
Mental capacity records
needs fixingSome decisions for people who lacked capacity were not assessed or recorded clearly as best-interest decisions. This could affect whether people's legal rights were properly protected.
“Some decisions had not been subject to this process.” from the report
Staff availability
needs fixingStaff supporting people with more complex needs were stretched at times. This delayed some personal care and limited some people's ability to attend activities when they needed staff support.
“the lack of staff availability at times had an impact on people's preferred times to get up” from the report
Involvement in care plans
minorMost people inspectors spoke with could not remember being involved in their care plans, although relatives or representatives were asked for comments when people could not contribute.
“most people we spoke with could not recall being involved in their care plans” from the report
- 01Have all staff now completed and had their induction signed off, including moving and handling and fire safety training?
- 02How often does each staff member receive supervision, and how is this checked?
- 03How many staff are normally available on the nursing floor at different times of day?
- 04How do you ensure people who need staff support can attend activities on every floor?
- 05How are mental capacity assessments and best-interest decisions recorded when someone cannot consent to their care or living arrangements?
This was an unannounced planned inspection covering all five CQC questions and both the care provided and the care home premises. This explanation was written from the published report of 2 May 2019 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 Pear Tree Court
2 rated inspections over 2 years: the service has slipped, from Good to Requires improvement.
- April 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019GoodSafe: GoodWell-led: Good
- February 2018
Registered with the Care Quality Commission on 1 February 2018.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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