CQC report explained · a nursing home
What the CQC found at Pendean House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, staffing levels were enough, and medicines were managed safely. Some people said they sometimes waited longer than was comfortable for a response to their call bell.
- Effective?
- Good
- Care plans had been improved and reflected people's needs and wishes. Staff supported nutrition, healthcare access and end-of-life care, and received training and supervision.
- Caring?
- Good
- People and relatives described staff as kind, patient and respectful. Inspectors saw that people were involved in decisions and supported to remain as independent as possible.
- Responsive?
- Good
- Care was personalised and people were supported with their interests, relationships, communication and end-of-life wishes. Some people who spent time in their rooms said they wanted more social contact.
- Well-led?
- Good
- Inspectors found a positive culture, clearer leadership and effective quality checks. The home had improved its systems after the previous inspection and used meetings, audits and feedback to monitor care.
What inspectors found, December 2019
Pendean House Care Home was rated Good; inspectors found kind, safe care and major improvements, but some people wanted more one-to-one social contact.
This was an unannounced inspection on 1 and 4 October 2019. Inspectors spoke with people, relatives, staff and visiting professionals. They reviewed care records, medicines records, staff files and records about how the home was managed.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with kindness and respect, their care plans had improved, medicines were managed safely and staffing levels met people's needs.
The report describes significant improvement since the previous inspection, which had been rated Requires Improvement with a breach of Regulation 9. The issues from that inspection had been addressed and the home was no longer in breach.
There were still some points to watch. Two commodes needed further cleaning during the visit, some people experienced longer waits for call bells, and people who spent time in their rooms said they felt lonely and wanted more social contact.
Kind and respectful care
People were treated as individuals and staff knew their routines, preferences and communication needs. Inspectors saw dignity and respect in staff relationships with people.
“People received high quality care and support from a staff team who valued and celebrated individuality and diversity.” from the report
End-of-life support
Staff worked closely with the local Macmillan team and supported people to make choices about their care and preferred place of death. Families spoke highly of the support they received.
“Staff were skilled in providing end of life care to people.” from the report
Improved care planning
Care plans had been rewritten and included people's needs, wishes and preferences. Staff had protected time to keep these records up to date.
“Care plans had improved by this inspection and the provider was no longer in breach of regulation 9.” from the report
Good involvement and activities
People helped shape menus, activities and other parts of the home. Activities were available seven days a week and the home had strong links with the local community.
“Activities were provided seven days a week.” from the report
Learning from the previous inspection
The home had acted on the earlier problems with risk records, medicines, care plans, mealtime support and quality checks. Inspectors found the provider was no longer in breach.
“There had been significant improvements in the service since our last inspection.” from the report
More cleaning was needed
minorInspectors found two commodes that needed further cleaning. Staff dealt with this quickly during the visit.
“During our visit we identified two commodes that required further cleaning.” from the report
Loneliness for some people
needs fixingSome people who preferred to stay in their rooms said they wanted more social contact and still felt lonely. The manager was looking at adding more one-to-one time and involving more care staff in activities.
“There is a lot of time sitting on your own” from the report
One lift was out of service
minorOne lift was not working during the inspection. A ramp allowed people to use the other lift, and the manager had sought advice from the fire and rescue service about this temporary arrangement.
“At the time of our visit, one lift was out of service.” from the report
- 01How much one-to-one time is now offered to people who prefer to stay in their rooms?
- 02What are the usual call bell response times, and how do you investigate longer waits?
- 03How often are commodes and other equipment checked and cleaned?
- 04Is the lift now working, and what arrangements are in place if it is out of service?
- 05How do you keep care plans up to date and make sure staff follow the latest information?
This was an unannounced comprehensive inspection of the care, premises and management of the home, covering all five CQC questions. This explanation was written from the published report of 25 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.
What inspectors found, October 2018
Rated Requires Improvement; inspectors found kind, compassionate care, but care plans, medicines records and oversight needed improvement.
This was an unannounced comprehensive inspection on 26 July 2018. It was brought forward after concerns about end of life care. Inspectors observed care, medicines and a mealtime, spoke with people, visitors and staff, and reviewed care records and management systems.
People receiving end of life care were receiving appropriate and compassionate care, with symptom management supported by the local Macmillan team. However, some care plans and risk assessments were out of date or did not explain people's current needs. Medicines records also contained errors and missing information.
The home was rated Requires Improvement overall. Caring was rated Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. The report says there was one breach of legal requirements, concerning person-centred care.
Kind and respectful care
People and relatives described staff as caring. Inspectors saw gentle, reassuring interactions and found that privacy and dignity were maintained.
“People were treated with kindness and respect. People were given choices and their independence was maintained.” from the report
End of life support
People receiving end of life care received appropriate and compassionate support. Staff worked with the local Macmillan team on symptom management.
“people were receiving appropriate and compassionate care and staff were delivering symptom management, under the guidance and support of the Macmillan team.” from the report
Activities and inclusion
The home offered activities seven days a week, trips and events. Staff also visited people in their rooms when they could not or did not want to attend group activities.
“There was an activity programme. This was discussed at residents' meetings to enable people to give their feedback and make suggestions about what should be included in the programme.” from the report
Training and recruitment
The home had checks for new staff, an induction process and a training programme. Staff had access to supervision and relevant health professionals were involved in people's care.
“There was a comprehensive system for staff training.” from the report
Care plans did not contain enough detail
seriousSome care plans and risk assessments did not reflect people's current needs. This made it harder for staff to know exactly what care to provide and was a breach of Regulation 9.
“This lack of individualised care plans is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2014” from the report
Medicines records had errors
needs fixingInspectors found a duplicated prescription and missing information for some creams, lotions and medicines given when needed. The report says the impact was low because nurses knew how to give the medicines, but the records and checks needed improvement.
“We identified errors in the medication administration record (MAR), including a duplicated prescription and a lack of documentation relating to topical and PRN medicines.” from the report
Quality checks missed problems
needs fixingAudits and management checks did not identify the problems found in care plans, medicines records and accident records. This meant the home's oversight was not consistently effective.
“Audits and systems of governance had failed to identify areas of concern and sustain improvement.” from the report
Meal support was inconsistent
needs fixingInspectors saw that one person did not eat their meal despite being offered encouragement. People also gave mixed views about the food.
“The lack of consistent support and encouragement, from staff, impacted on the lunch-time experience.” from the report
Some waits for staff
needs fixingPeople gave mixed accounts of how quickly staff responded to requests. Some relatives also described poorer responses at night or at weekends.
“However, people told us different things, in relation to staff responding to bells or requests.” from the report
- 01How have you updated care plans and risk assessments so they clearly reflect each person's current needs?
- 02What checks now make sure medicines administration records contain the correct prescriptions and instructions for creams and medicines given when needed?
- 03How do you monitor staff response times at night, at weekends and during busy periods?
- 04How will you support people who need encouragement or help to eat and drink?
- 05How are mouth care and other changing needs recorded for people receiving end of life or short-stay care?
This was an unannounced comprehensive inspection covering all five CQC questions, brought forward because of concerns about end of life care. This explanation was written from the published report of 23 October 2018 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 Pendean House Care Home
4 rated inspections over 3 years: the service has held its Good rating throughout.
- December 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2017Goodstayed GoodWell-led: Requires improvement
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 15 November 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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