CQC report explained · a residential care home
What the CQC found at Pedmore House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was preventing and managing infections. This included visitor controls, PPE, testing, hygiene, social distancing and outbreak arrangements.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Pedmore House was inspected but not rated; inspectors were assured about infection prevention during a COVID-19 outbreak.
This was an announced, targeted inspection on 3 February 2021. Inspectors looked at infection prevention and control measures because of the coronavirus pandemic.
The home had seven people living there and could support up to 11 people. Inspectors were assured that the home managed visitors, shielding, social distancing, PPE, testing, hygiene and infection outbreaks appropriately.
People had been isolated in their rooms because of the outbreak. Records on bedroom doors helped staff keep track of when people had been seen and why they entered rooms.
The home was inspected but not rated. This report does not give an overall quality rating or ratings for all five areas of care.
Visitor controls
During the recent outbreak, visitors were not allowed to enter except in exceptional circumstances. A separate entrance was used in those cases.
“The provider was following best practice guidelines in ensuring visitors to the home did not introduce or spread COVID-19.” from the report
PPE and handwashing
Staff were following PPE guidance, with extra PPE points near people's rooms. Extra precautions were used when social distancing was not possible.
“Staff were adhering to Personal Protective Equipment (PPE) guidelines and extra PPE locations had been set up near to people's' rooms.” from the report
Staff support
Staff had individual COVID-19 risk assessments, regular wellbeing conversations and an app for sharing updates.
“The provider had ensured that all staff had received a personal COVID-19 risk assessment and conversations about their wellbeing were held regularly .” from the report
Room observation records
During room isolation, records on bedroom doors helped staff know when each person had been seen and why staff had entered.
“Observational records were put on each bedroom door to ensure staff were aware of when each person had been seen and the reason for entering the room.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visits managed now, including visits in exceptional circumstances?
- 02How do you make sure staff use PPE and handwashing correctly when social distancing is not possible?
- 03How often are staff tested, and how are people using the service tested?
- 04What arrangements are used if someone needs to isolate in their room?
- 05How do you prevent and manage infection outbreaks, and when was the infection prevention and control policy last updated?
This was a targeted inspection of infection prevention and control measures during the coronavirus pandemic; it was not a full inspection of all five areas of care. This explanation was written from the published report of 3 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, April 2019
Pedmore House was rated Good overall and in all five areas; inspectors found safe, kind and personalised care.
This was an unannounced, planned inspection on 6 March 2019. One inspector reviewed information held by the CQC, spoke with two people living at the home, one relative, two care workers and the registered manager. They also observed care and checked care records, recruitment, complaints, accidents and quality checks.
The home was caring for 11 people with learning disabilities or dementia. Inspectors found enough staff, safe recruitment and safe medicines management. Staff understood how to manage risks and report possible abuse. People received suitable food, healthcare and support with decisions under the Mental Capacity Act.
People described staff as kind and said they were given choices. Staff knew people's preferences and supported individual activities, including outings. Complaints had been investigated and resolved, and the home had systems to monitor quality and act on feedback.
The overall rating was Good, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection, published on 3 December 2015.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs. Recruitment checks and medicines records were also in place.
“People were supported by staff who knew how to report concerns of abuse and manage risks to keep people safe.” from the report
Kind and respectful care
Staff had built warm relationships with people and respected their dignity. They supported people to make choices and remain as independent as possible.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Staff knew people's preferences, past lives and interests. Care records included choices about routines, food, culture and communication.
“Both staff and the registered manager demonstrated that they knew people very well.” from the report
Activities and feedback
People had individual activity boards and were supported with activities and outings that interested them. The home acted on feedback about activities.
“People told us they were able to access activities that met their individual interests.” from the report
Quality oversight
The home carried out monthly checks on areas including the environment, medicines and care files. Identified improvements were acted on.
“There were systems in place to monitor the quality of the service.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and record my relative's particular risks and health conditions?
- 02How will you support my relative's communication needs and involve them in day-to-day choices?
- 03What activities and outings would be suitable for my relative's interests and abilities?
- 04How will you meet my relative's dietary needs and preferences?
- 05How can I give feedback or make a complaint, and how will you keep me informed of the outcome?
This was an unannounced inspection of the care home, including the premises and care provided, and it assessed all five CQC questions. This explanation was written from the published report of 11 April 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 Pedmore House
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 20 November 2012.
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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