CQC report explained · a nursing home
What the CQC found at Peartree Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable risk assessments, safe medicines arrangements, safer recruitment, enough staff and effective safeguarding. They also found strong infection control measures, including cleaning, testing, vaccination support and PPE.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Inspectors found improved quality checks, clearer communication, open handling of concerns and positive engagement with people, relatives and staff.
What inspectors found, March 2021
Rated Good; inspectors found safe, well-managed care, although risk audits did not always confirm that planned safety measures were in place.
This was an announced focused inspection on 9 March 2021. Inspectors checked Safe and Well-led after an earlier inspection found legal breaches and the service completed an improvement plan. The inspection was also prompted partly by a serious injury and concerns about equipment risks.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found suitable risk assessments, safe medicines systems, safer recruitment, enough staff and strong infection control measures. People and relatives said they felt safe and supported.
Managers had improved audits, communication and oversight. The home had acted on earlier concerns and was meeting Regulation 12 at this inspection. The other three question ratings were not reassessed and were carried forward from the previous comprehensive inspection.
People felt safe
People and relatives told inspectors they felt safe and knew how to raise concerns. Staff understood their safeguarding responsibilities.
“People we spoke with told us they felt safe using the service and relatives told us they were confident raising concerns.” from the report
Medicines were managed safely
Medicines records reviewed were completed properly. Managers checked records each shift, and staff had training and competency checks.
“We reviewed a number of MAR charts and saw these were completed appropriately.” from the report
Infection control
The home had measures for COVID-19 testing, vaccination, PPE, isolation and enhanced cleaning. Inspectors found the building clean and hygienic.
“The building was kept clean, fresh-smelling and hygienic.” from the report
Management had improved
The home completed its improvement plan after the previous inspection. Managers had strengthened audits, communication and oversight.
“The service successfully delivered an action plan to address concerns identified at our last inspection.” from the report
Learning from incidents
Managers reviewed incidents and changed practice after an injury linked to a hot water bottle. The home stopped using hot water bottles and gel packs.
“The provider had investigated this and changed policies across the organisation to prohibit the use of bottles and gel packs to reduce the risk of a recurrence.” from the report
Risk audits did not always check action was completed
needs fixingAudits checked whether risk plans were suitable and up to date, but did not always make sure the planned safety measures were in place. This was a shortfall in checking practice.
“Audits were carried out on risk management plans, to check that these were still suitable and in date, but did not always ensure that mitigation measures were in place.” from the report
- 01How do you now check that the safety measures written in each person's risk plan are actually in place?
- 02What changes were made after the serious injury linked to equipment, and how are these changes monitored?
- 03How often are medicines records checked, and what happens if a missed or incorrect dose is found?
- 04How will relatives be kept informed about visits, activities and changes to the home?
- 05Which ratings from the previous inspection apply to Effective, Caring and Responsive, and when will these areas next be fully inspected?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 27 March 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, December 2019
Requires Improvement; inspectors found kind, person-centred care, but serious safety and management failures put people at risk.
This was an unannounced inspection on 24 and 26 September 2019. Inspectors spoke with people, relatives and staff, and checked care plans, medicines, staff records and quality checks.
People generally had positive experiences. Staff were described as caring and knowledgeable. The home was clean, activities were varied, food choices were supported, and people were treated with dignity and respect.
However, some safety plans were not followed. Medicines were not always managed safely, and fridge temperature problems had not been identified by the home's checks. These issues put people at risk of harm.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. This was worse than the previous overall Good rating in April 2017.
Kind and respectful staff
People and relatives spoke positively about the staff. Inspectors saw warm interactions and found that staff supported privacy, dignity and choice.
“The atmosphere of the home was warm and friendly.” from the report
Clean environment
The home was well maintained and very clean. Staff were following suitable infection control procedures and had enough protective equipment.
“The home was visibly very clean and smelled fresh throughout.” from the report
Activities and inclusion
There was a wide choice of activities, events and outings. These reflected people's interests, cultures, faiths and diversity.
“There was a wide range of activities, events and outings.” from the report
Staff skills and support
Staff completed an induction and relevant training. They received supervision and appraisal and were supported with personal development.
“Several staff told us that training was a particular strength of the home.” from the report
Risk plans were not followed
seriousRecords did not always show that people's risks were being monitored as required. One person had very low recorded fluid intake and incomplete monitoring when they became unwell.
“Failure to follow risk management plans put people at risk of serious harm.” from the report
Medicines and thickening powders
seriousAn as-required medicine was being given routinely without clear evidence it was needed every night. Thickening powders were also found in an unlocked cupboard, creating a serious risk if accidentally consumed.
“Failure to ensure proper and safe management of medicines placed people at risk of serious harm.” from the report
Unsafe fridge checks
seriousThree dining-area fridges had very high temperatures. One had recorded high temperatures since March 2017, but audits had not identified the problem.
“The recent internal audit records we saw showed that the responsible member of staff had signed to say they had checked these fridges and found no concerns.” from the report
Weak quality checks
needs fixingThe home's audits failed to identify significant safety problems. Some nursing staff also did not consistently complete monitoring and records.
“There was a system of quality assurance checks and audits in place, but these had failed to identify the significant safety issues and breaches of the regulations we found during the inspection.” from the report
Nutrition records
needs fixingPeople's nutritional needs were assessed, but daily records were not always kept properly. Refresher training was planned to improve this.
“However, daily records were not always appropriately kept to monitor people's nutrition.” from the report
- 01How are you now checking that each person's risk management plan is followed, especially for drinking, nutrition and changes in health?
- 02How are as-required medicines being reviewed to make sure they are only given when needed?
- 03Where are thickening powders stored now, and how do you prevent people from accessing them accidentally?
- 04How are fridge temperatures checked, recorded and escalated if they are outside safe limits?
- 05What checks now confirm that nursing staff complete monitoring and records correctly?
This was a planned, unannounced inspection covering all five key questions; Safe and Well-led fell from Good to Requires Improvement, while Effective, Caring and Responsive remained Good. This explanation was written from the published report of 5 December 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 Peartree Care Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- March 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 December 2010.
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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