CQC report explained · a residential care home
What the CQC found at Pear Tree Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2022
Pear Tree Residential Care Home was rated Requires Improvement, with serious weaknesses in leadership, safety, staffing and person-centred care.
This was an unannounced inspection on 8 August 2022. Two inspectors visited, an Expert by Experience contacted relatives, and the inspectors spoke with people, staff and relatives. They also checked care, medicines, staffing, training and management records.
The home was not always safe. Inspectors found medicines were not always managed correctly, fire doors were wedged open, a defective hoist was still being used, infection control was weak and the building was not always clean. Staffing levels and staff training were also not always sufficient.
People did not always receive enough activities or stimulation. The provider had not acted properly on complaints, feedback or advice from other organisations. Records and checks were not reliable enough to identify and fix problems.
The overall rating changed from Good to Requires Improvement. Safe and Effective were rated Requires Improvement, while Well-led was rated Inadequate. Caring and Responsive were not inspected during this visit, so their previous ratings carried over into the overall rating.
People felt safe
People and relatives told inspectors they felt safe at the home. Staff understood how to report safeguarding concerns.
“People and their relatives told us they felt safe at the service.” from the report
Kind staff
Relatives gave positive feedback about staff being warm, caring and welcoming.
“They are very warm and caring and have an excellent rapport with Mum.” from the report
Healthcare links
People were supported to access healthcare, and a relative described communication with healthcare professionals as good.
“They have a good working relationship with the Primary Health groups such as the local GP practice.” from the report
Access to snacks
Food and drink were available, including snacks that people could access in the lounge.
“Food and drink were available to people; this included a fridge in the lounge with snacks in for people to access.” from the report
Fire and equipment risks
seriousFire safety concerns had already been raised by the local authority and fire service but remained unresolved. A hoist with a known defect was still in use during the inspection.
“Fire doors were sometimes routinely wedged open with wedges and some doors were not fully closing into the casing.” from the report
Medicines were not always safe
seriousEight people's medicine stocks were incorrect. Storage checks and handwritten medicine records did not always meet expected standards.
“People did not receive their medicines as prescribed. We checked medicines stocks and found eight people's medicines stock was incorrect.” from the report
Weak infection control
seriousInspectors saw poor use and storage of protective equipment. Cleaning was not always completed and parts of the home were dirty or worn.
“Staff and management were not always wearing PPE in line with guidelines.” from the report
Staffing and training
seriousThere were not always enough staff, including domestic and activities staff. Training records did not show that staff had all the skills needed for people's care.
“Failure to have sufficient numbers of staff is a breach of Regulation 18, (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Too little stimulation
needs fixingPeople did not always receive enough activities or social engagement. Four people told inspectors they were bored.
“Four people told us they were bored and there was a lack of activities.” from the report
Leadership did not fix known problems
seriousAudits, records and feedback systems did not identify or resolve important concerns. The provider had not acted sufficiently on earlier recommendations, complaints or professional advice.
“The provider had failed to improve the service enough and has consistently not had a good rating in the well-led domain for the past six inspections.” from the report
- 01What has been done to stop fire doors being wedged open and to make sure all fire doors close properly?
- 02How are medicines now checked, stored and administered, and how were the eight incorrect medicine stocks resolved?
- 03What staffing levels are now provided on each shift, including domestic and activities staff?
- 04What training and competency checks have all staff completed, particularly for medicines, diabetes and insulin support?
- 05What activities are now available, and how are residents' requests and complaints being recorded and acted on?
This was a focused inspection of Safe and Well-led, later expanded to Effective; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 7 October 2022 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, June 2021
Pear Tree Residential Care Home was rated Good overall; inspectors found safe, kind care, but leadership and quality checks still needed improvement.
This was an unannounced focused inspection on 12 April and 7 May 2021. One inspector spoke with staff and relatives, observed care, checked the home, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe. Inspectors found suitable staffing, safe medicines administration, risk assessments, fire checks and infection control. Safeguarding concerns had been investigated and action had been taken, although staff had not always raised concerns quickly enough.
The home was rated Requires Improvement for Well-led. Audits were completed, but some were not detailed enough and one PPE audit did not reflect current guidance. The overall rating stayed Good because the other areas were not inspected during this visit and earlier ratings were carried forward.
Safe staffing
Inspectors found enough staff to meet people's needs safely and without avoidable delay. Relatives gave positive feedback about staff.
“Staffing levels were appropriate to meet people's needs and enabled staff to support people in a timely manner.” from the report
Kind and respectful care
Staff were attentive, kind and supported people in a personalised way while maintaining their dignity.
“We observed people being supported in a personalised manner and their dignity being maintained.” from the report
Medicines and infection control
People received their medicines safely, and the home followed infection prevention and control measures, including current visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Learning from incidents
The provider reviewed safeguarding concerns, accidents and incidents, and introduced further staff training and reminders.
“The provider had reviewed the concerns and taken measures to implement learning, which included further training for staff” from the report
Safeguarding was not always reported promptly
seriousStaff had not always raised safeguarding concerns in a timely way. Inspectors said this placed people at risk of abuse, although staff understood the process by the inspection.
“However, staff had not always raised concerns in a timely manner, which placed people at risk of abuse.” from the report
Quality audits were not reliable enough
needs fixingAudits needed more development. Some records were not detailed enough to be checked by the provider, and a PPE audit was out of date.
“Completed audits were not always detailed which meant information could not be double checked by the provider.” from the report
Some medicine instructions lacked detail
needs fixingInstructions for some medicines given only when needed did not contain enough detail to ensure all staff would use them consistently.
“Some protocols required more detail to ensure all staff could administer them consistently.” from the report
- 01How do you make sure all safeguarding concerns are reported immediately and reviewed by management?
- 02What has changed in the audit system since the inspection, and how do you check that audits are detailed and up to date?
- 03Have the instructions for medicines given when needed been rewritten with enough detail for every member of staff?
- 04How do you gather and act on feedback from residents, relatives and professionals now that COVID-19 restrictions have changed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from previous comprehensive inspections. This explanation was written from the published report of 4 June 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.
Every inspection of Pear Tree Residential Care Home
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
Read what inspectors found at Pear Tree Residential Care Home →
- June 2021Goodstayed GoodSafe: GoodWell-led: Requires improvement
Read what inspectors found at Pear Tree Residential Care Home →
- October 2019Goodstayed GoodWell-led: Requires improvement
- June 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 3 February 2011.
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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