CQC report explained · a residential care home
What the CQC found at Pendennis Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines, staffing, recruitment and infection control were generally managed safely, although some risk assessments and medicines instructions needed more detail.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found a positive, person-centred culture. Management checks, feedback systems and learning from incidents were used to monitor and improve care.
What inspectors found, August 2023
Pendennis Residential Care Home is rated Good; inspectors found people safe and well supported, but some care records needed more detail.
This was an unannounced focused inspection on 15 and 19 June 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives, staff and health professionals, and checked care, medicines, recruitment and management records.
The home was rated Good overall, with Good ratings for Safe and Well-led. People said they were happy and felt safe. Inspectors found enough safely recruited staff, safe medicines systems, infection control arrangements and systems to protect people from abuse.
Inspectors found some risk assessments did not clearly explain all the actions staff needed to take. Some as-required medicines instructions also needed more personalised information. The manager said these records were being reviewed or had been addressed after the inspection.
The other three key question ratings were not inspected during this visit. The overall rating used ratings from the previous comprehensive inspection, which was published in December 2018.
People felt safe
People said they were happy and felt safe. Staff understood how to report abuse and inspectors found systems to protect people from avoidable harm.
“Systems were in place to protect people from the risk of abuse and avoidable harm.” from the report
Enough suitable staff
Inspectors found enough staff to meet people's needs. Recruitment checks, including references and DBS checks, were completed before staff started.
“People were supported by sufficient numbers of staff to meet their needs.” from the report
Medicines managed safely
Staff were trained and checked as competent before giving medicines. Medicines were ordered, stored, disposed of and audited through suitable systems.
“Medicines were managed safely and there were appropriate procedures in place for medicines to be ordered, stored and disposed of safely.” from the report
Strong management checks
The management team checked areas including infection control, medicines, care records and the environment. The service also used feedback and incidents to identify improvements.
“The management team carried out a range of checks which were effective and covered areas such as infection control, medicines management, care records and health and safety of the environment.” from the report
Risk records lacked detail
needs fixingSome risk assessments did not clearly record the actions staff needed to take. This could lead to different staff providing care in different ways, although risks were being managed in practice.
“some records did not clearly state what action staff needed to take to mitigate risk which could lead to inconsistencies in care delivery.” from the report
As-required medicines instructions
needs fixingSome instructions for as-required medicines needed more personalised information so staff could give them appropriately. The manager said this had been addressed after the inspection.
“we found some protocols would benefit from further person-centred information to ensure people received them appropriately.” from the report
- 01How have you updated risk assessments so they clearly explain the actions staff must take for each person's risks?
- 02What personalised information is now included in instructions for as-required medicines?
- 03How do you make sure all staff know about changes to a person's risks and care instructions?
- 04What were the ratings and findings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the overall rating used the other ratings from the previous comprehensive inspection published on 8 December 2018. This explanation was written from the published report of 26 August 2023 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 2018
Rated Good; inspectors found kind, safe care, with some gaps in staff availability and care plan detail.
This was an unannounced comprehensive inspection on 22 and 23 October 2018. Inspectors observed care, spoke with people living at the home, relatives, staff and a health professional, and checked care records, medicines, staff files, safety records and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were treated kindly and respectfully. Inspectors found suitable staffing overall, safe medicines management, trained staff, good support with food and healthcare, activities, and a management team that listened and acted on feedback.
There were two specific shortfalls. People in the lounge were left without staff support for up to 20 minutes on one afternoon, and one care plan did not explain how staff should help a person change position in bed. The home was still rated Good overall and remained Good from the previous inspection in March 2016.
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff respond attentively when people needed help or became distressed.
“People were treated with dignity and respect. Staff were kind, respectful and spoke with people considerately.” from the report
Safe medicines and risk management
Medicines were ordered, stored and given safely. Care records included risk assessments covering areas such as falls, nutrition, moving and handling, and skin care.
“People continued to receive their medicines safely and as prescribed by their GP.” from the report
Good staff support
Staff had relevant training, supervision and appraisals. Recruitment checks were completed before staff started work.
“The support staff received from the provider in the form of training, supervision and appraisal enabled staff to provide effective care.” from the report
Choice and meaningful activities
People were offered choices about daily routines, meals and activities. Group and individual activities were available, and people could choose not to take part.
“Activities on offer were displayed for people to see and were numerous, including games, arts and crafts, films, music and chair exercises.” from the report
Management listened to feedback
The provider used questionnaires and quality checks. It had started a whole-home refurbishment programme after people commented that some decoration looked tired.
“This demonstrated that people's views were listened to and acted upon and showed that the provider valued people, putting their wellbeing, comfort and happiness first.” from the report
Staff cover in communal areas
needs fixingOn one afternoon, people in the lounge were without staff support for up to 20 minutes. One person waiting to use the toilet did not have a staff member nearby to respond.
“However, we did observe that during the afternoon on the first day of the inspection, people sitting in the lounge were not supported by staff for up to 20 minutes.” from the report
Some care plan detail was missing
needs fixingOne care plan did not explain how staff should help a person change position in bed. Inspectors said this could mean staff did not have all the information needed to keep the person safe and meet their needs.
“This meant staff may not have all the information they need to keep people safe and meet their needs and preferences.” from the report
- 01How do you make sure a staff member is always available in communal areas, including during busy afternoon periods?
- 02What action was taken after inspectors found people in the lounge without staff support for up to 20 minutes?
- 03How do you check that every care plan explains the exact support each person needs, including help with changing position in bed?
- 04What refurbishment work has been completed since the inspection, and what work remains?
- 05How do you monitor people who choose to spend much of their time in their rooms so they do not become socially isolated?
This was an unannounced comprehensive inspection covering all five rating areas, and the overall rating remained Good from the previous inspection in March 2016. This explanation was written from the published report of 8 December 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 Pendennis Residential Care Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Pendennis Residential Care Home →
- December 2018Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Pendennis Residential Care Home →
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 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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