CQC report explained · a residential care home
What the CQC found at Pendle Brook Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines, health and safety risks, weight checks and nutrition records were not always managed properly. Staffing, recruitment, infection control and accident reporting were more satisfactory.
- Effective?
- Requires improvement
- People's needs were not always fully assessed, training was not fully up to date and food and fluid records were incomplete. Inspectors also found that best-interest decisions were not always recorded.
- Caring?
- Good
- People were treated with dignity and respect, and their equality and diversity needs were respected. People and relatives could share their views and were involved in care planning.
- Responsive?
- Requires improvement
- Care records were not always person-centred, up to date or complete. Activities and communication support were available, but feedback about meals and activities was mixed.
- Well-led?
- Requires improvement
- Quality checks did not always identify problems with medicines, risks, training and records. The manager was applying to become registered, and staff gave positive feedback about the new manager, although morale was mixed.
What inspectors found, September 2022
Pendle Brook Care Home is rated Requires Improvement; inspectors found kind care, but medicines, risk management and oversight were not reliable.
Inspectors carried out an unannounced inspection over several days. They spoke with six people living at the home, two relatives and eight staff. They reviewed care plans, medicines records, staff recruitment files and management records.
The home was caring, and people said they felt safe. Staffing levels and recruitment were adequate. Infection control, visiting arrangements, activities and learning from accidents were also areas that worked well.
There were important shortfalls. Medicines were not always managed safely, risk records and care plans were incomplete, and some staff training was out of date. Records and quality checks did not reliably identify or address these problems.
The overall rating remains Requires Improvement. Caring was rated Good. Safe, Effective, Responsive and Well-led were rated Requires Improvement. The provider remained in breach of Regulations 12 and 17.
Kind and respectful care
People were treated with dignity and respect. Staff supported people to remain as independent as possible.
“Staff supported people to be as independent as possible and respected their privacy and dignity.” from the report
Safe staffing and recruitment
Inspectors found staffing levels were adequate and recruitment checks had improved since the previous inspection.
“Staffing levels were adequate and recruitment processes were safe.” from the report
Infection control and visiting
Inspectors were assured that infection prevention measures were in place and people could receive visitors.
“People were supported to have visitors in line with current government guidance.” from the report
Learning from accidents
Accidents and incidents were recorded, and lessons were discussed with staff to support improvement.
“Lessons learned was discussed during staff meetings to help drive improvement.” from the report
Medicines were not always safe
seriousOne medicine was given after its disposal date, and eight stock records did not match the medicines held. Inspectors said this put people at risk of harm.
“Systems were either not in place, not being followed or not robust enough to demonstrate medicines safety was effectively managed.” from the report
Risks and care records were incomplete
seriousSome health risk assessments were missing. People were not always weighed as required, and nutrition records were incomplete.
“The provider had failed to ensure they were mitigating the risks to people's health or to regularly monitor the safety of the environment.” from the report
Quality checks did not find problems
seriousAudits failed to identify issues found by inspectors, including concerns about medicines, risks, training and record keeping. Some records were missing, inaccurate or out of date.
“Audits had not always identified areas for improvement.” from the report
Training was not fully up to date
needs fixingThe training record showed that not all staff had completed their required training. Inspectors recommended that the provider review training compliance.
“However, we found the training matrix identified that not all staff were up to date with training.” from the report
Meals needed improvement
needs fixingFood and fluid charts were not always completed properly. Some people said the meals were poor or repetitive.
“Sometimes food is horrible and sometimes it is good” from the report
Best-interest decisions were missing
needs fixingSome decisions about restrictions, including sensor mats, did not have the required best-interest records. Inspectors recommended that the provider review this process.
“Best interest decisions were not always in place; we saw examples of people who used sensor mats and had no best interest decisions in place around this.” from the report
- 01What changes have been made to prevent medicines being given after their disposal date?
- 02How are you now checking that medicine stocks match the records?
- 03Have all residents' care plans and health risk assessments been reviewed and completed?
- 04What training is still outstanding, and how are you making sure staff complete it?
- 05What changes have been made to improve meals and record people's food and fluid intake?
This was an unannounced inspection covering all five key questions and infection prevention and control; the report says the inspection activity ran from 20 to 30 June 2022 and visits took place on 20 and 22 June. This explanation was written from the published report of 14 September 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, November 2021
Pendle Brook Care Home is rated Requires Improvement; inspectors found caring staff but gaps in safety checks, care records and quality monitoring.
This was an unannounced focused inspection on 05 October 2021. Inspectors looked only at Safe and Well-led because the inspection followed concerns about staffing, recruitment and infection control. They spoke with people, relatives and staff, toured the building and checked care, medicine, recruitment and management records.
People and relatives said they felt safe and were treated well. Medicines were managed safely, staff understood safeguarding, and the home was generally clean. However, inspectors found missing or incomplete checks, including fire safety and environmental checks. Records did not always show that people had been weighed, given pressure relief or supported according to professional advice.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. This was a change from the previous overall rating of Good, published on 9 July 2021. The other three key questions were not inspected at this visit, so their previous ratings were carried forward.
People felt safe
People and relatives said staff treated people well and that the home had safety measures in place, including after falls.
“People living in the home told us they felt safe and that staff treated them well.” from the report
Medicines were managed safely
Inspectors found that people received their medicines as prescribed. Senior staff were trained and assessed as competent to administer them.
“Records reviewed showed people had received their medicines as prescribed.” from the report
Approachable management
People said the management team listened, and staff described managers as supportive and approachable.
“People told us the management team were approachable and always willing to listen.” from the report
Safeguarding awareness
Staff had safeguarding training and knew how to recognise and report possible abuse or harm.
“Staff had completed training in safeguarding adults.” from the report
Incomplete safety checks
seriousRequired fire safety and environmental checks had not been completed regularly. Night-time fire evacuation drills had not tested whether the available staffing would be enough to evacuate people safely.
“This meant the provider could not be certain staff would be able to evacuate people safely at night in the event of a fire or other emergency.” from the report
Care records did not always show required support
seriousRecords did not always show that people had been weighed or given pressure relief when their assessments said this was needed. Nutritional records were incomplete, and advice from a dietitian was not clearly followed in one person’s records.
“Records showed people had not always been weighed or received pressure relief in line with assessed risks.” from the report
Quality checks were not effective
seriousThe provider’s audits had not identified the problems found by inspectors. This led to a breach relating to governance and monitoring.
“Although the provider had a system of audits, these had not been effective in identifying the shortfalls we found during the inspection in relation to care records and checks regarding fire safety and the environment.” from the report
Infection control training gaps
needs fixingSome staff had not been trained in putting on and removing PPE correctly, and one staff member disposed of PPE incorrectly. A visitor record linked to COVID-19 testing and exposure was also incomplete.
“Some staff told us they had not completed training in the correct way to put on and take off PPE.” from the report
Recruitment checks
needs fixingRecruitment was generally safe, but the provider needed to fully investigate gaps in employment histories and track time limits on the right to work.
“We recommend the provider reviews their processes to ensure safe recruitment practices are always followed.” from the report
- 01What fire safety and environmental checks are now completed, how often are they reviewed, and when was the last night-time evacuation drill?
- 02How do you make sure care records show that weighing, pressure relief, nutrition support and professional advice have been completed?
- 03What has changed in the recruitment process to check employment gaps and right-to-work expiry dates?
- 04Which staff have now completed training on putting on, removing and disposing of PPE correctly?
- 05How is the new management team checking that audits identify problems, and has a manager registered with CQC?
This was a focused inspection of Safe and Well-led only; the other three key-question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 3 November 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 Pendle Brook Care Home
3 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2021GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- May 2019
Registered with the Care Quality Commission on 23 May 2019.
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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Most charge £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
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